
G!ass_ 
Book. 



COPYRIGHT DEPOSIT 



ATLAS AND EPITOME 



GYNECOLOGY 



DR. OSKAR SCHAEFFER 
1 1 

Privatdocent of Obstetrics and Gynecology in the University 
of Heidelberg 



AUTHORIZED TRANSLATION FROM THE SECOND 
REVISED AND ENLARGED GERMAN EDITION > 

EDITED BY 

RICHARD C. NORRIS, A.M., M.D. 

Surgeon-in-charge, Preston Retreat, Philadelphia; Gynecologist to the Methodist 
Episcopal Hospital and to the Philadelphia Hospital ; Consulting Gyne- 
cologist to the Southeastern Dispensary and Hospital for Women and 
Children; Lecturer on Clinical and Operative Obstetrics, 
Medical Department, University of Pennsylvania. 



WITH 207 COLORED ILLUSTRATIONS ON go PLATES, 
AND 62 ILLUSTRATIONS IN THE TEXT 



PHILADELPHIA 
W. B. SAUNDERS & COMPANY 
I goo 
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18524 



Of 



Libr*t/ y of Con< 

JUL 12 1900 

Copvrgnt tntiy 

S£amn COPY. 

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JUL 13 1900 






Copyright, 1900, by W. B. Saunders & Company. 



71043 



PRESS OF 
W. B. SAUNDERS & COMPANY. 



EDITOR'S PREFACE. 



The value of this Atlas to the medical student and to 
the general practitioner will be found not only in the con- 
cise explanatory text, but especially in the illustrations. 
It occupies a position midway between the quiz compend 
and the more pretentious works on gynecology. The 
large number of illustrations and colored plates, reproduc- 
ing the appearance of fresh specimens, will give the stu- 
dent an accurate mental picture and a knowledge of the 
pathologic changes induced by disease of the pelvic organs 
that can not be obtained from mere description. JNext to 
the study of specimens, which for evident reasons are not 
available outside of large clinics, well-chosen illustrations 
must be utilized. The Atlas serves that purpose so well 
that its translation and publication for the English-speak- 
ing profession seemed very desirable. 

The translator, Dr. W. Hersey .Thomas, has carefully 
followed the author's te^^wln^h, while concise, covers 
the subject systematically, and with sufficient detail to give 
the reader a comprehensive knowledge of gynecologic dis- 
orders. The paragraphs devoted to the treatment of the 
various diseases are very conservative, in some instances 
perhaps too much so for the aggressive surgeon. The 
author's conservatism will be appreciated, however, by 
the student and the practitioner, who necessarily wish to 
be informed on nonoperative gynecology. 

Editorial comments have occasionally been inserted, in 
order to harmonize or point out the difference between 
the author's teaching and that generally approved in 
America. 



PREFACE TO THE SECOND 
EDITION. 



Every one concerned in the production of the second 
edition of this volume has helped to make it represent all 
the advances in our technical knowledge. A statement 
of the latest scientific acquisitions has been incorporated 
into the original text. The greatest stress has been laid 
upon the accumulation of new illustrative material from 
autopsies and operations as well as from the living. The 
delineations of the artist, Mr. A. Schmitson, are meri- 
torious and true to nature. The new material has been 
obtained partly from the Heidelberg Pathologic Institute, 
partly from our surgical and gynecologic clinics, and partly 
from my private practice. I take this opportunity to 
express my heartiest thanks to the Directors of the Insti- 
tute, to Professors Arnold, Czerny, Kehrer, and their 
assistants, and especially to Professors Ernst and Jordan 
for the use of their instructive fresh specimens. 

The publisher has spared neither trouble nor expense 
in the reproduction of the water-colors, which are abun- 
dant and as true to nature as possible. 

O. SCHAEFFER. 



PREFACE TO THE FIRST EDITION. 



In spite of the existence of excellent shorter works and 
compends, as well as of good comprehensive atlases, the 
author feels that there is need of a book that will give the 
student and the practitioner an opportunity to elucidate 
and to complete his necessarily limited personal observa- 
tions and examinations in the clinic and dispensary. If 
the entire work were carried out upon a purely diagram- 
matic basis, it would probably be more readily grasped by 
the majority of readers ; not every one, however, possesses 
the gift of translating such pictured relations into living 
clinical entities. On the other hand, the strict reproduction 
of anatomic preparations renders difficult that clear repre- 
sentation which is necessary to sift the essential from the 
nonessential facts. 

I have consequently decided, in many cases, to combine 
both methods of illustration — that is, to reproduce accu- 
rate anatomic specimens, and then to emphasize more 
sharply the changes under consideration. I have further 
endeavored to show every subject from as many stand- 
points as possible (that is, regarding their etiology, develop- 
ment, secondary influence, progress, and termination), and 
consequently have further elucidated the pictures of speci- 
mens by diagrammatic and semidiagrammatic drawings. 

Thanks to my former assistantship at the Munich 
Frauenklinik, and in no slight degree to the indulgent 
permission and stimulating counsel of Professor v. 
Winckel, I have been able to employ, almost without ex- 
ception, original anatomic and clinical material. I wish 
to take this opportunity to express my thanks to this 

3 



4 PREFACE TO THE FIRST EDITIOX. 

gentleman, and also to Professor Kehrer, who most 
amiably allowed me to use his clinical material. 

The text has been divided into two parts. The con- 
tinuous text is, without exception, written from a practical 
standpoint ; the text of the, plates, on the contrary, con- 
tains the purely theoretic, scientific, anatomic, microscopic, 
and chemic notes, and facts of general significance (con- 
cerning sounds, pessaries, etc.), so that in referring to the 
work the one text will not have a disturbing influence 
upon the other. 

To avoid needless repetition, frequent references have 
been made to my " Atlas of Obstetric Diagnosis and 
Treatment/' The necessity for this will be readily under- 
stood when we consider the identity of the anatomic data 
and the intimate mutual relations existing between the 
child-bearing process and the majority of gynecologic 
affections. 

The material has been classified from an etiologic stand- 
point as for as possible ; to carry this out rigidly, how- 
ever, would have led to diffuseness. The chapters upon 
sepsis, gonorrhea, genital tuberculosis, and venereal dis- 
eases are based upon this classification. Cystitis, which 
comes within the domain of the gynecologist so frequently, 
has received special attention. 

Particular effort has been directed to the clear presenta- 
tion of the subject of differential diagnosis. The methods 
which I have chosen are the comparative and the tabular. 
The subject receives full attention in the chapters on 
Myomata, Cystomata, Carcinoma, Tumors of the Ante- 
uterine and Retro-uterine Spaces, and others. 

At the conclusion of the work I have placed a Thera- 
peutic Table of the ordinary remedies used in gynecology, 
and have indicated the appropriate methods of prescribing 
them — chiefly as intra-uterine pencils, vaginal and rectal 
suppositories, baths, and injections. 

O. SCHAEFFEE. 

Heidelbeeg, Xo vernier, 1895. 



CONTENTS. 



Group I.— Anomalies of Formation and Arrested Develop= 

ment. 

CHAPTER I. 

PAGE 

Fetal Anomalies of Formation 17 

\ 1. Aplasia and Hypoplasia of the Fetal Rudiments ... 17 
§ 2. Hyperplastic Anomalies of Formation of the Fetal 

Rudiments 29 

CHAPTER II. 

Arrested Development and Anomalies of Infancy and 

Puberty 35 

\ 3. Infantile Anomalies of Formation 35 

| 4. Anomalies of Menstruation 38 

\ 5. Sterility 46 

Group II. — Changes of Shape and Position. 

CHAPTER I. 

Hernia 48 

\ 6. Hernia and Other Changes of Shape of the Vulva . . 48 

CHAPTER II. 

Inversion and Prolapsus 50 

# 7. Inversions of the Vagina and Uterus 50 

\ 8. Prolapse of the Vagina and Uterus. — Elevatio Uteri . 57 

The Normal Situation and Position of the Uterus . . 57 

CHAPTER III. 
Pathologic Positions, Versions, and Flexions of the 

UTERUS 73 

§ 9. Pathologic Positions of the Uterus and Its Adnexa . . 73 

| 10. Anteversions and Anteflexions of the Uterus 76 

\ 11. Retroversions and Retroflexions of the Uterus .... 79 

Directions for the Application of Pessaries .,..., 84 

5 



b CONTEXTS. 

Group III. — Inflammatory and Nutritional Disturbances. 

CHAPTER I. page 

Inflammation axd Its Coxsequexces : Acquired Stexoses 
axd Atresias, Coxtractiox of Orgaxs, Exudations, axd 

Adhesioxs . 92 

\ 12. Gonorrhea 93 

| 13. Chronic Endometritis. Erosion and Ectropion of the 

External Os 100 

Catarrh of the Cervix and Chronic Cervicitis and Their 

Consequences : Erosion and Ectropion 101 

Endometritis Corporis Uteri 107 

\ 14. Chronic Metritis Ill 

| 15. Sepsis (Acute Vulvitis, Vaginitis, Endometritis, Myo- 
metritis, Salpingitis, Parametritis and Perimetritis, 

Peritonitis) 117 

\ 16. Chronic Salpingitis 124 

| 17. Chronic Oophoritis 126 

| 18. Chronic Perimetritis, Oophoritis, and Salpingitis. 

Chronic Pelvic Peritonitis 131 

\ 19. Chronic Parametritis and Paracolpitis 134 

l 20. Genital Tuberculosis 136 

\ 21. Venereal Diseases 139 

\ 22. Catarrh of the Bladder and Cystitis 140 

CHAPTER II. 

g 23. Disturbances of Nutrition and Circulation. Neuroses 149 

Group IV.— Injuries and Their Consequences. 

CHAPTER I. 

Defects with Cicatricial Changes 155 

\ 24. Injuries of the Vulva ( Including Fissures ) and Perineal 

Defects, Incontinentia Vulvae .155 

\ 25. Lacerations of the Vagina and Cervix ....... 160 

| 26. Traumatic Stenoses and Atresias of the Vulva, of the 

Vagina, and of the Uterus 162 

CHAPTER II. 

Fistulas 165 

\ 27. Classification of Fistulas 165 

A. Fistulas of the Urinary Organs 165 

B. Intestinal Fistulas 168 

CHAPTER III. 

Traumatic Effusioxs of Blood 175 

I 28. Hematoma: (a) Vulvar ; (b) Extraperitoneal . . . . 175 
| 29. Intraperitoneal Retro-uterine Hematocele 176 



CONTENTS. i 

CHAPTER IV. page 

Foreign Bodies in the Genital Canal and in the 

Bladder 180 

\ 30. Foreign Bodies (Including Vesical Calculi) 180 

Group V.— New Growths. 

CHAPTER I. 

Benign Tumors 186 

\ 31. Benign Tumors of the Mucous Membranes Covered 

with Squamous Epithelium 186 

\ 32. Benign Tumors of the Uterus 189 

| 33. Benign Tumors of the Uterine Adnexa 199 

CHAPTER II. 

Tumors of Benign Structure That May Become Dan- 
gerous under Certain Conditions 202 

I 34. Fibromyomata 202 

| 35. Ovarian Cystomata 211 

CHAPTER III. 

Malignant Tumors 234 

\ 36. Malignant Tumors of the Vulva, Bladder, and Vagina 234 

| 37. Malignant Tumors of the Uterus ... 237 
| 38. Malignant Tumors of the Adnexa, Especially of the 

Ovaries 245 

I. Carcinoma 245 

II. Sarcoma 247 

Therapeutic Table 249 

Index 263 



LIST OF PLATES. 



PAGE. 

Plate 1. — The Vulva of a Nonpregnant Multipara. Anomaly of 

the Hymen 32 

Plate 2. — Fig. 1. — Intra vaginal Cervix of an "Infantile" 

Uterus 32 

Fig. 2. — Duplication of Cervix in a Case of Uterus Bi- 
cornis Septus with a Single Vagina. 
Plate 3. — Fig. 1. — Impressio Fundi Uteri 54 

Fig. 2. — Partial Inversion of the Uterus. 

Fig. 3. — Complete Inversion of the Uterus. 

Fig. 4. — Complete Inversion and Prolapse of the 
Uterus. 

Fig. 5. — Complete Prolapse of the Retroflexed Uterus 
and of the Vagina, with Laceration of the 
Perineum ; Cystocele. 
Plate 4. — Fig. 1 . — Incomplete Prolapse of a Retro verted Uterus ; 

Marked Rectocele ; Vaginal Inversion . . 58 

Fig. 2. — Incomplete Prolapse of the Uterus, Due to 
Hypertrophy of the Intermediate Portion 
of the Neck ; Inversion of the Vagina with 
Cystocele. 

Fig. 3. — Total Prolapse of Anteflexed Uterus and of 
the Anterior Vaginal Wall, with Cysto- 
cele ; Characteristic Flexion of the 
Urethra. 

Fig. 4. — Complete Prolapse of Retroflexed Uterus 
(First Degree) and of Vagina. 
Plate 5. — Fig. 1. — Prolapse of Posterior Vaginal Wall ; Recto- 
cele ; Descent of Retroflexed Uterus ( Sec- 
ond Degree) . . 58 

Fig. 2. — Prolapse of Anterior Vaginal Wall ; Extreme 
Grade of Cystocele ; Anteflexion of the 
Uterus (First Degree) ; Descent of the 
Uterus. 

Fig. 3. — Reposition of Prolapsed Uterus by a Mar- 
tin Stem-pessary. 

Fig. 4. — Hypertrophy of the Anterior Lip of the 
Uterus, Producing Inversion of the Ante- 
rior Vaginal Wall and Cystocele. 
Plate 6. — Inversion of the Posterior Vaginal Wall. Leukorrhea. 62 

9 



^i 



10 



LIST OF PLATES. 



Plate 7. — Fig. 1. — Inversion of the Vagina from a Perineal 

Tear of the Third Degree 64 

Fig. 2. — View of the Cervix in a Case of Elevation of 
the Uterus. 
Plate 8. — Complete Prolapse of an Anteflexed Uterus ; Cysto- 

cele 68 

Plate 9. — Extreme Inversion of the Vagina, with Cystocele and 

Incomplete Prolapse of the Retroverted Uterus . . 70 
Plate 10. — Incomplete Prolapse of the Uterus ; Simple Erosion ; 

1 i Circular ' ' Thickening of Cervix ; Rectocele ... 70 

Plate 11, — Anteflexion of the Uterus in a Child 72 

Plate 12. — Incomplete Prolapse of the Uterus ; Elongation of the 
Intermediate Portion of the Neck, with 1 1 Circular ' ' 
Hypertrojmy of the Vaginal Portion ; Inversion of 

the Anterior Vaginal Wall ; Cystocele 74 

Plate 13. — Artificial Prolapse for Operative Purposes, with the 

Arising Inversion of the Vagina and with Cystocele 74 
Plate 14. — Fig. 1. — Normal Anteversion of the Uterus ..... 78 
Fig. 2. — Pathologic Anteversion of the Uterus. 
Fig. 3. — Myoma of the Anterior Uterine Wall, Simu- 
lating an Anteflexion of the Second or 
Third Degree. 
Fig. 4. — Anteversion of a Fixed Uterus (at the Same 
Time Retroposition from a Full Bladder). 
Plate 15. — Fig. 1. — Anteflexion of the Uterus of the Second De- 
gree from Posterior Perimetritic Ad- 
hesions 80 

Fig. 2. — Anteflexion of the Uterus of the First De- 
gree with the Neck Lying Horizontally. 
Fig. 3. — Anteflexion of the Infantile Uterus with 
Stenosis of the Cervix and Internal Os ; 
Dysmenorrhea. 
Fig. 4. — Anteflexion of the Uterus of the Third De- 
gree from a Submucous Uterine Polyp. 

Plate 16. — Fig. 1. — Retroversion of a Fixed Uterus 80 

Fig. 2. — Retroflexion of a Fixed Uterus (First De- 
gree). 
Fig. 3. — Slight Retroflexion and Descent of the Puer- 
peral Uterus from Relaxation of the Geni- 
talia. 
Fig. 4. — Retroversion of the Uterus (Third Degree) 
from Pressure of an Ovarian Cyst. 
Plate 17.— Fig. 1. — Encapsulated Peritoneal Exudate in Doug- 
las' Pouch. Descent and Anterior 

Position of a Fixed Uterus 82 

Fig. 2. — Retroposition of the Uterus by a Full Blad- 
der. 
Fig. 3. — Descent and Retroflexion of the Uterus of 
the First Degree, Brought About by Re- 
laxation of the Folds of Douglas. 



LIST OF PLATES. 11 

PAGE. 

Plate 17. — Fig. 4. — Retroflexion of the Uterus of the First De- 
gree 82 

Plate 18. — Fig. 1. — Retroversion of the Uterus from Two Intra- 
mural Myomata 86 

Fig. 2. — Transition from Retroversion to Retroflexion 
of the Uterus from an Intramural Myoma 
of the Anterior Wall. 
Fig. 3. — Retroflexion of the Uterus of the Third De- 
gree. 
Fig. 4. — Inveterate Retroflexion of the Uterus of the 
Third Degree. 
Plate 19. — Fig. 1. — Retroversion of the Uterus ; Vaginal Ovario- 
cele 86 

Fig. 2. — Bimanual Examination from the Rectum of 

a Case of Cord-like Total Atresia of the 

Vagina with a Rudimentary Solid Uterus. 

Plate 20. — Fig. 1. — Reposition of a Retro verted Uterus by Means 

of Kustner's Bullet-forceps 88 

Fig. 2. — Reposition of a Retroverted Uterus by Means 

of the Sound. 
Fig. 3. — Introduction of the Elastic Ring of Mayer by 

Means of Fritsch's Forceps. 
Fig. 4. — Introduction of Hodge's Pessary. 
Plates 21 and 22. — Manual Reposition of a Retroflexed Uterus . 90 

Plate 23.— Massage (Thure Brandt) 90 

Plate 24. — Fig. 1. — Gonorrheal Papilloma of the Cervix 

(Mracek) 94 

Fig. 2. — Gonorrheal Cervicitis. 
Fig. 3. — Gonococci and Pus-corpuscles. 
Plate 25. — Bartholinitis Dextra Gonorrhceica. Perforation of the 

Abscess ; Urethritis 96 

Plate 26. — Bartholinitis Sinistra Gonorrhceica. Abscess Forma- 
tion (Mracek) 96 

Plate 27. — Gonorrheal Vulvitis and Vaginitis 98 

Plate 28. — Fig. 1. — The Microscopic Structure of the Parts of 

the Vulva 98 

Fig. 2. — Longitudinal Section Through the Cervix in 

a Case of Old Prolapse of the Uterus. 
Fig. 3. — Simple, Papillary, and Follicular Erosion of 
the Cervix. 

Plate 29.— Fig. 1.— Elephantiasis Vulvae 100 

Fig. 2. — Condyloma Acuminatum. 

Fig. 3. — Vaginal Secretion. 

Fig. 4. - Cross-section of an Ovule of Naboth. 

Plate 30.— Fig. 1.— Normal Uterine Mucosa 102 

Fig. 2. — Hyperplastic Glandular Endometritis. 
Fig. 3. — Malignant Adenoma (Glandular Cancer). 
Fig. 4. — Hypertrophic Glandular and Interstitial 
Endometritis. 
Plate 31. — Fig. 1. — Acute Interstitial Endometritis 104 



12 LIST OF PLATES. 



PAGE. 

Plate 31. — Fig. 2. — Chronic Interstitial Endometritis 104 

Fig. 3. — Postabortive Endometritis. 
Plate 32. — Fig. 1. — Marked Congestion and Beginning Simple 
Erosion of the Posterior Lip of the Os, as 
a Sign of Uterine Inflammation; Endome- 
tritis and Metritis 106 

Fig. 2. — Slight Congestion of the Cervix of a Multi- 
para with a Characteristic, Broad, Fis- 
sured External Orifice. 
Plate 33. — Fig. 1. — Congenital Simple Erosion of the Cervix of 

a Virgin , 106 

Fig. 2. — Leukorrhea and Simple Erosion. 
Plate 34. — Ectropion, with Extreme Relaxation of the Cervical 

Wall and Intact Commissures of the External Os . 108 
Plate 35. — Mucous Polyp and Ectropion of the Anterior Lip of the 

Uterus 108 

Plate 36. — Fig. 1. — Different Molds of the Uterocervical Canal 

as Shown by Swollen Laminaria .... 110 
Fig. 2. — Curetment in Fungous Endometritis. 
Plate 37.— Fig. 1.— Chronic Metritis with Ovula Nabothi ... 112 
Fig. 2. — Gonorrheal Endometritis with Simple Ero- 
sion and Ovules of Xaboth ; Inflammatory 
Hyperemia. 
Plate 38. — Retroversion of the Fixed Uterus (First Degree) and 

Agglutination of the Cervix (Acquired) .... 112 
Plate 39. — Acute Purulent Pelvic Peritonitis (Peritonitis of Per- 
foration) 114 

Plate 40. — Fig. 1. — Acute Catarrhal Parenchymatous Salpingitis 

(Due to Gonococci and Streptococci) 118 

Fig. 2. — Hematosalpinx. 
Fig. 3. — Pyosalpinx. 
Plate 41. — Fig. 1. — Acute Purulent Parenchymatous and Inter- 
stitial Salpingitis 122 

Fig. 2. — Parametritis Acuta of the Broad Ligament. 
Fig. 3. — Chronic Oophoritis with Oligocystic Degen- 
eration. 
Plate 42. — Double Py ©hydrosalpinx, Chronic Adhesive Perime- 
tritis and Oophoritis 124 

Plate 43. — Chronic Adhesive Perimetritis and Salpingitis with 

Uterine Myomata .... 126 

Plate 44. — Pelvic Peritonitis, Peri-oophoritis, Perisalpingitis, and 

Right-sided Pyosalpinx 128 

Plate 45.— Fig. "1.— Pelvic Peritonitis 130 

Fig. 2. — Left-sided Dermoid C} T st Perforating into 
the Rectum. 
Plate 46. — Genital Tuberculosis of Both Tubes, of Both Ovaries. 

and of the Pouch of Douglas . . . . .132 
Plate 47. — Cystitis; Ureteritis (Pyonephrosis) as a Result of Lith- 
iasis ; Metritis with Endometritis Fungosa ; Cervici- 
tis with Marked Dilatation of the Cervical Canal : 
Yaginitis 134 



LIST OF PLATES. 



13 



PAGE. 

Plate 48. — Chronic Cystitis with Acute Exacerbations 136 

Plate 49. — Fig. 1. — Syphilitic Ulcer of the Vaginal Cervix. 

(Mracek.) 138 

Fig. 2. — Syphilitic Ulcers of the Vaginal Mucosa. 
(Mracek. ) 
Plate 50. — Papular Gummata of the Vulva, of the Anus, and of 

the Inner Side of the Thigh. (Mracek.) 140 

Plate 51. — Fig. 1. — Elephantiasis Vulvae Originating in the La- 
bium Ma jus Dextrum and Polypoid Ex- 
crescences of the Mucous Membrane at the 

Urethral Orifice 152 

Fig. 2 —Phlebectasia of the Labia Majora, of the Cli- 
toris, and of the Nymphae ; the Eight 
Labium Ma jus Contains a Hematoma 
(Thrombus Vulvas) ; and Hemorrhoids. 
Plate 52. — Edema of the Nymphae from a Moribund Patient with 

a Cardiac Lesion ... 154 

Plate 53. — Phlebectasia with Phleboliths of the Ligmenta Lata 
Corresponding to the Ovarian Vessels and the Pam- 
piniform Plexus 156 

Plate 54. — Fig. 1. — The Normal Perineum 158 

Fig. 2. — Perineal Laceration of the Third Degree 

( into the Rectum ) . 
Fig. 3. — Perineal Laceration of the Second Degree. 
Fig. 4. — Perineal Laceration of the Third Degree. 
Plate 55. — Fig. 1. — Torsion of the Cervix Produced by Scar Tis- 
sue . . 162 

Fig. 2. — Star-shaped Laceration of the External Os. 

Plate 56. — Fig. 1. — Laceration of the Left Commissure of the Os 

Uteri, with Marked Ectropion and Ovules 

of Naboth on the Projecting Hyper- 

trophied Cervical Mucosa . . 162 

Fig. 2. — Old Ectropion and Congestion of the Cervix. 

Plate 57. — Recto-uterine Hematocele in Combination with an 

Extra-uterine Gestation Sac . 174 

Plate 58. — Fig. 1. — Free Ascites in the L T pright Position . . . 178 
Fig. 2. — Intraperitoneal Retro-uterine Hematocele. 
Fig. 3. — Extraperitoneal Retro-uterine Hematoma. 
Fig. 4. — Large Subserous Posterior Myoma of the 
Uterus Simulating a Retroflexion. 
Plate 59. — Fig. 1. — Left-sided and Posterior Parametritis . . . 182 
Fig. 2. — Intraligamentous and Retroperitoneal Mul- 
tilocular Glandular Mucoid Cyst of the 
Left Ovary. 
Fig. 3. — Left-sided Pyosalpinx. 

Fig. 4. — Carcinomatous Cystadenoma of the Ovary. 
( Diagrammatic. ) 
Plate 60. — Fig. 1.— Polyps of the Uterine Mucous Membrane . 188 

Fig. 2. — Simple Erosion with Ovules of Naboth. 
Plate 61. — Fig. 1. — Subserous Polvpoid Fibromvoma of the 

Uterus . / 188 






14 LIST OF PLATES. 

PAGE. 

Plate 61.— Fig. 2.— Myomatosis Uteri 188 

Plate 62. — Several Polypoid Myomata of the Fundus, which Pro- 
duced Uncontrollable Hemorrhage at the Time of 

the Menopause 190 

Plate 63. — Intraperitoneal Surface of an Amputated Myomatous 

Uterus (Submucous Myoma) 192 

Plate 64. — Several Bleeding Myomatous Polyps of the Fundus . 194 

Plate 65. — Completely Extirpated Myomatous Uterus 194 

Plate 66. — Inner Surface of a Uterus with an Incised Intramural 
Submucous Hemorrhagic Myoma of the Posterior 

Wall 196 

Plate 67. — Polypoid Subserous Fibromyoma; Polyps of the Mu- 
cous Membrane in the Dilated Cervical Canal . . . 204 

Plate 68.— Fig. 1.— Unilocular Ovarian Cysts 210 

Fig. 2. — Thin-walled Multilobular Glandular Mucoid 
Cyst. 

Plate 69.— Multilocular Glandular Mucoid Cyst 212 

Plate 70.— Multilocular Glandular Mucoid Cyst 214 

Plate 71. — Fig. 1. — Histologic Structure of a Uterine Mucous 

Polyp 214 

Fig. 2. — Microscopic Section through the Transition 
Zone of a Minute Myoma that is Becom- 
ing Encapsulated into the Surrounding 
Normal Uterine Muscularis. 
Fig. 3. — Vaginitis (Colpitis). 
Plate 72. — Fig. 1. — Primary Formation of Cysts from a Multi- 
locular Glandular Mucoid Cyst of the 

Ovary 220 

Fig. 2. — Papillary Proliferating Cyst of the Ovary. 
Fig. 3. — Necrotic Cyst- wall. 

Fig. 4. — Sediment from the Fluid of an Ovarian 
Cyst. 

Plate 73. — Fig. 1. — Myxosarcoma of the Uterus 222 

Fig. 2. — Spindle-cell Sarcoma of the Uterus. 

Fig. 3. — Malignant Adenoma Growing through a 

Cyst- wal 1 . ( Semi-diagrammatic . ) 
Fig. 4. — Angioma of the Urethra. 
Plate 74. — Figs. 1 and 2. — Bimanual Examination of a Pyosal- 
pinx with a Full and with an Empty 

Eectum . 226 

Fig. 3. — Bimanual Examination, with Assistance, of 
the Pedicle of an Ovarian Cyst. 
Plate 75. — Figs. 1 and 2. — Two Different Cut Surfaces of a Sar- 
coma of the Ovary 228 

Plate 76.— Fig. 1.— Sarcoma of the Ovary , . . 228 

Fig. 2. — A Case of Commencing Sarcomatous Degen- 
eration of the Ovary. 
Plates 77 and 78. — Multiple Extraperitoneal Extravasations of 

Blood, Especially in the Great Omentum 230 
Plate 79. Fig. 1.— Epithelioma of the Vulva 232 



LIST OF PLATES. 



15 



PAGE. 

Plate 79. — Fig. 2. — Part of an Epitheliomatous Papilloma of 

the Vaginal Cervix 232 

Fig. 3. — Epitheliomatous " Pearls " from an Ulcer 

of the Cervix. 
Fig. 4. — Dermoid Cyst. 
Plate 80. — Fig. 1. — Ulcerated Epithelioma of the Left Labium 

Majus 236 

Fig. 2. — Flat Ulcerating Epithelioma of the Poste- 
rior Lip of the Os Uteri and of the Poste- 
rior Vaginal Vault. 
Plate 81. — Fig. 1. — Nodular Epithelioma of the Vaginal Cervix. 
Fig. 2. — Epitheliomatous Papilloma of the Anterior 

Lip of the Os Uteri 236 

Plate 82. - A View of an Epitheliomatous Ulceration of the Mu- 
cous Membrane of the Cervical Canal ...... 238 

Plate 83. —Figs. 1 and 2. — Epitheliomatous Ulcer of the Cervix. 240 
Plate 84. — Fig. 1. — Epitheliomatous Papilloma of the Anterior 
Lip of the Os Uteri and of the Anterior 

Vaginal Vault . 240 

Fig. 2. — Beginning Epithelioma of the Cervix. 
Plate 85. — Fig. 1. — Epitheliomatous Papilloma of Both Lips of 

the Os 242 

Fig. 2. — Epitheliomatous Ulcer of the Cervix. 
Plate 86. — Fig. 1. — Epithelioma of the Cervix that has Perfo- 
rated into the Bladder 242 

Fig. 2. — Perforation of an Epithelioma of the Cervix 
into the Bladder and Rectum. 

Plate 87. — Fig. 1. — Carcinoma of the Uterine Body 244 

Fig. 2. — Sarcoma of the Uterus. 
Plate 88.— Fig. 1.— Flat Cervical Epithelioma of Both Lips of 
the Os Uteri Involving Both Vaginal 

Vaults 244 

Fig. 2. — Epitheliomatous Papilloma of Both Lips of 

the Os Uteri. 
Fig. 3. — Polypoid Epitheliomatous Papilloma of the 

Anterior Lip of the Os Uteri. 
Fig. 4. — Epitheliomatous Papilloma of the Posterior 
Lip of the Os Uteri Filling the Entire 
Posterior Vaginal Vault. 
Fig. 5. — Villous Cancer of the Bladder in Its Most 

Frequent Position. 
Fig. 6. — Rectal Carcinoma (Glandular Cancer) Infil- 
trating the Rectovaginal Septum. 
Plate 89. — Fig. 1. — Cancer Xodules in the Cervix. Which Has 

Not Yet Ulcerated 246 

Fig. 2. — Epitheliomatous Ulcer of the Cervix. 

Fig. 3. — Epitheliomatous Ulcer of the Cervix Which 

Has Invaded the Uterine Body. 
Fig. 4. — Carcinoma of the Body of the Uteres Which 
Has Perforated into the Bladder 



16 LIST OF PLATES. 



Plate 89. --Fig. 5. — Epitheliomatous Ulcer of the Cervix Which 

Has Perforated into the Bladder .... 246 

Fig. 6. — Epitheliomatous Ulcer of the Cervix Per- 
forating into Both Bladder and Eectum. 
Plate SO. — Fig. 1. — Fungous Endometritis and Ectropion . . 246 

Fig. 2. — Epitheliomatous Papilloma of Both Lips of 
the Os. 

Fig. 3. — Ovules of Naboth in a Mucous Polyp Visible 
at the Os Uteri. 

Fig. 4 — Fibroid Polyp Separating the Lips of the Os 
Uteri. 



Tab. 1. 







ne 



DUPLICATION. 



33 



explains the association of all degrees of the bicornate 
uterus with septa of varying extent in the uterus or vagina. 
We may thus have a uterus bicornis septus or bicollis, 
and subseptus or unieollis, or, again, both may be com- 
bined with vagina septa or subsepta. (Plate 2, Fig. 2, 
and Figs. 20 and 21.) One duct may be occluded, as has 
been already mentioned, producing a unilateral atresia. 
A hymen septus or bifenestratus may be present, and, by 




Fig. 21. — Uterus et vagina septa (Munich Frauenklinik). 



reason of its resisting power, may play quite an important 
role in the pathology of the sexual life. (Fig. 2.) 

Symptomatology. — The influence of these malforma- 
tions upon labor has been described in my " Atlas of 
Obstetric Diagnosis and Treatment." 

Conception frequently does not occur in consequence 
of the feeble development of the entire genitalia. These 
individuals are usually weaklings with amenorrhea, and 
should be advised not to marry. 
3 



34 ANOMALIES OF FORMATION. 

Treatment. — Ligation or division (Paquelin) of the 

septa. It is to be remembered that after castration or 
total extirpation of the uterus for myomata the presence 
of a third ovary may nullify the result, or may explain 
a subsequent abdominal pregnancy. 



CHAPTER II. • 

ARRESTED DEVELOPMENT AND ANOMALIES OF 
INFANCY AND PUBERTY. 

1. Uterus fetalis (often planifundalis). 

2. Uterus infantilis and uterus membranaceus. 

3. Anteflexio uteri infantilis. 

4. Stenosis cervicis et orificii externi. 

5. Stenosis vulvovaginal or hvmenalis. 

6. Evolutio prsecox. 

7. Oligomenorrhea and amenorrhea. 

8. Dysmenorrhea. 

9. Menorrhagia . 
10. Sterility. 

|3. INFANTILE ANOMALIES OF FORMATION. 

1 and 2. Those formative arrests designated as uterus 
fcetalis or infantilis are combined with functional distur- 
bances (symptoms) — to be described under the headings 
from 3 to 10 — and with a generally weakened constitution, 
Idiocy, etc. In the fetal form the body of the uterus fails to 
grow, and the neck is relatively larger ; the vaginal cervix 
is very small, and is provided with a minute opening. 
The latter is also true of the infantile uterus (Plate 2, Fig. 
1), but here the body has grown until its muscular coat is 
as well developed as is that of the neck. The body, instead 
of being pear-shaped and forming the largest part of the 
uterus, is simply a cylindric continuation of the cervix. 

The uterus membranaceus is due to a simple primary 
atrophy of the organ. (Fig. 22.) All three forms are 
characterized by their diminutiveness. 

35 



36 



ANOMALIES OF F0R3IATI0K 



The diagnosis is made by bimanual exploration (through 
the rectum, if necessary) and by the cautious introduction 
of the uterine sound. 1 

Treatment. — Treat the anemia or tuberculosis with 
roborants. Increase the local blood supply by massage, 
warm sitz-baths, stimulating vaginal douches, the stem- 
pessary, frequent scarifications, and mustard plasters on 
the thighs during the menstrual molimina. Faradization 
is also employed, one pole being introduced into the 
uterus and the other being placed upon 
the mons veneris. 

3 and 4. Infantile anteflexion 
(Plate 15, Fig. 3) of a small organ is 
often associated with stenosis of the 
cervical canal or its external orifice. 
" Puerile anteflexion " consists in a 
sharp bending forward of a normal, 
large, flexible organ, with a shortened 
anterior vaginal wall, in the elongated 
axis of which the hypertrophic supra- 
vaginal cervix is found. 

Symptoms. — Dysmenorrhea (8) 
and sterility. Both may be purely 
mechanical, from the narrowed lumen, 
or the angle of flexion, especially when 
the latter has become rigid from long 
duration and secondary inflammatory 
changes. The more frequent cause of both, however, is 
the passive hyperemia and the resulting congestive endo- 
metritis, while the sterility is still further accounted for 
by the frequent hypoplasia. 

Diagnosis. — After emptying the bladder the anteflexion 
is recognized bimanually, the form and direction of the 
vagina being noted. (Plate 22.) The sound demon- 
strates the direction of the cervix and the size of its 




Fig. 22. -Uterus 
membranaceus. 



1 The normal length of the uterus, as measured by the sound, is six 
centimeters. 



INFANTILE ANTEFLEXION 37 

lumen, 1 whether it is narrowed throughout or at one of its 
orifices only, and whether secondary dilatation of the uter- 
ine cavity or cervical canal has taken place. (Plate 1 5, 
Fig. 3.) 

Treatment. — If no other cause for the symptoms exists 
(an endometritis, for example), the stenosis should be re- 
moved by dilatation with metal sounds, laminaria tents, or 
iodoform-gauze tampons every few weeks. A more per- 
manent result is obtained by making, immediately after 
the period, bilateral transverse incisions, about one centi- 
meter deep, in the cervical commissures by means of 
Cooper's scissors. The mucous membrane of the cervical 
canal is then brought into apposition with that of the in- 
tra vaginal cervix in such a manner that the two rows of 
stitches pass from the anterior to the posterior cervical lip 
and the uterine orifice gapes. The fresh surfaces are so 
liable to form adhesions after this operation of Sims' that it 
is better to make four radiating incisions (Kehrer), or to 
transplant a flap, with a pedicle, from the cervix to the 
incision. This is followed by a tamponade of ferripyrin 
cotton, which is nonirritating. In stenosis of the entire 
cervical canal faradization should be employed, with the 
negative pole in the cervix (fifty milliamperes for five 
minutes, twice a week for two months). 

The anteflexion is treated by the introduction of a 
stem-pessary made of silver. The stem should be from 
2 to 3 mm. thick, the length from 1 to 1J cm. shorter 
than the uterine cavity, and the plate from 2 to 2J cm. 
in diameter (v. Winckel). If the direct introduction of 
the stem is impossible, it may be introduced alongside of 
a sound. It is to be held in position for a few days by a 
tampon, and the patient kept quiet. If an inflammatory 
reaction occurs, the tampon is to be removed. This stem 
seems not only to remove the flexion, but also to act favor- 
ably on the dysmenorrhea and sterility (v. Winckel). It 

1 The normal cervical canal will accommodate a sound four milli- 
meters in diameter. 



38 ANOMALIES OF MENSTRUATION. 

stimulates and invigorates the organ. The vagina should 
be washed out daily, and the stem should be changed 
every few months. [The dangers involving the use of 
intra-uterine stem-pessaries have caused them to be aban- 
doned by most practitioners. Forcible dilatation and 
overstretching of the cervical canal by means of graduated 
bougies or branched dilators are now usually employed. 
The endometritis resulting from the stenosis and aggra- 
vating the symptoms renders a thorough curetment a neces- 
sary part of the operation of dilating the cervical canal for 
stenosis causing dysmenorrhea and sterility. — Ed.] 

5. Stenosis Vulvo vaginalis or Hymenalis. — Inci- 
sion is necessary only in a marked degree of vagina in- 
fantilis, and then a flap should be transplanted. Should 
the hymen be too resistant and interfere with coitus, it 
should be incised and appropriately sutured, since forced 
immissio penis or the descending head has caused lateral 
lacerations from which considerable hemorrhage has oc- 
curred. The more insignificant stenoses are to be dilated, 
either quickly or slowly, with iodoform gauze. In neuro- 
pathic individuals simultaneous spasms of the constrictors 
often occur. (See Vaginismus.) 



§ 4. ANOMALIES OF MENSTRUATION. 

Physiologic menstruation commonly appears first at 
puberty (from the age of fourteen to sixteen years in our 
climate ; earlier in warmer countries ; in large cities 
earlier than in the country), and is a sign of sexual 
maturity. It occurs as a hemorrhage, dependent upon a 
regular monthly determination of blood to the genitalia, 
in consequence of which the uterine mucous membrane 
becomes more vascular, spongy, and better fitted for the 
reception and development of an impregnated ovum. 
Ovulation occurs at the same time, and is due to the es- 
cape of a mature ovum from a ruptured Graafian follicle. 
The entire process (ovulation and menstruation) is regu- 



OLIGOMENORRHEA AND AMENORRHEA. 39 

lated by a newous center, and goes hand in hand with 
periodic variations in the body-metabolism, which is least 
active at the time of the menstrual flow. The hemor- 
rhage has its source in the mucous membrane of the 
uterine cavity, and recurs periodically unless pregnancy 
supervenes. (See " Atlas of Obstetric Diagnosis and 
Treatment," second edition, § 1.) 

Various disturbances may precede or accompany men- 
struation, and are to be looked upon as expressions of 
fluctuations in the body-metabolism. These are : Exan- 
themata (herpes labialis, acne), skin irritations, chilliness, 
neuralgia, malaise, dizziness, borborygmus, diarrhea with 
suddenly appearing constipation, a preceding leukorrhea 
for several days, a more frequent desire to urinate, and a 
urine loaded with urates. 

6. Evolutio Praecox. — In these cases menstruation may 
occur during childhood, and the individual may present all 
the appearances of sexual maturity. 1 Should she become 
pregnant, delivery will usually take place without special 
difficulty. 

7. Oligomenorrhea and Amenorrhea. — Etiology, 
— In §§ 1-3 we have already found a series of causes for 
amenorrhea in the anomalies of development of the gen- 
italia. These can be divided into : 

(a) Permanent organic causes : defects of the uterus, 
ovaries, or Graafian follicles (either congenital or resulting 
from an infantile oophoritis), with otherwise completely 
developed genitalia. 

(b) Functional disturbances, which persist in some cases : 
infantile genitalia (hypoplasia, anteflexion, stenosis, in- 
sufficient development of the uterine mucosa), anemia, 
especially in neuropathic individuals (lack of determina- 
tion of blood to the uterus). 

(c) Mechanical obstructions : atresias. 

(d) Affections that cause a symptomatic amenorrhea : 

1 The not infrequent hemorrhages from the genitalia of the new- 
born should be excluded from this classification. 






40 ANOMALIES OF MENSTRUATION. 

morphinism ; obesity ; severe acute diseases ; excessive 
disturbances of the circulation from catching cold or from 
emotional excitement (fright, fear of pregnancy) ; diseases 
of the genitalia, such as metritis (contraction of the mucous 
membrane), perimetritis (ovaries and tubal ostia embedded 
in exudate), and oophoritis ; ovarian tumors ; puerperal 
hyperinvolution (atrophy of the genitalia) ; and pregnancy. 
The latter causes a physiologic amenorrhea, but neverthe- 
less it should be noted that ovulation and conception may 
occur. 

Treatment. — It should first be determined whether the 
case is one of true amenorrhea or whether it is caused by 
mechanical hindrances (congenital or acquired) to the exit 
of blood. The treatment of the latter conditions (groups 
a and c), both curative and symptomatic, has been fully 
described in § 1. (See Plate 38.) 

Group b (see § 3) requires a tedious yet often a fruitful 
line of treatment. The careful regulation of the manner 
of living is of the utmost importance. Every injurious 
influence should be removed, the more pernicious being : 
overexertion, especially that of a mental nature (hard study ; 
constant application to school-exercises, embroidery, or 
sewing ; frequent visits to theaters, balls, etc.) ; too 
much or too little sleep ; exhausting diarrhea or leukor- 
rhea ; masturbation ; and the ingestion of improper food. 
The diet should at first be bland, nutritious, and of such 
a nature that constipation and tympanites are avoided ; 
meat diet later. The household duties are to be regularly 
arranged; if possible, daily walks of one or two hours in 
the country are to be recommended, taking care to avoid 
fatigue ; the bowels must be regulated (fruit, abdominal 
massage, injections of lukewarm water with or without 
soap or oil, laxatives). Certain drugs stimulate the appe- 
tite and are of value. Especially useful are blood tonics, 
such as Hommel's hematogen (hemoglobinum liq.), Dah- 
men's hemalbumin powder, nutrol, wine with peptonate 
of iron, or Blaud's pills with tincture of cinchona. 



OLIG OMENORRHEA— TEE A T3IEXT. 4 1 

The circulation should be encouraged by warm foot- 
baths (95° to 100° F., with a few teaspoonfuls of salt or 
mustard, once or twice daily), warm sitz-baths or full 
baths, and the application of sinapisms to the thighs when 
congestion of the pelvic viscera and a mucous vaginal dis- 
charge point to a menstrual epoch. Cold baths should be 
forbidden. The patient should be warmly clothed. Sea 
air is beneficial, from its stimulating effect upon the appe- 
tite. Nervous, chlorotic girls are benefited by the rest-cure 
(Weir Mitchell-Playfair). For the local treatment see § 3. 
The importance of massage should not be forgotten. 

Group d calls for treatment of the primary affection. 
It is in this class of cases alone that stimulating drugs are 
to be used : potassium permanganate, sodium salicylate, 
santonin, and aloes. Their use is by no means productive 
of uniform success. Hyperin volution is treated by mas- 
sage and electricity. (See § 3, Stenosis.) 

Dependent upon the amenorrhea, the following secon- 
dary conditions are observed : 

a. Marked disturbances of metabolism, which lead to 
dyspepsia of a severe type, tympanites, and secondary 
anemia. 

,5. Vicarious hemorrhages from other mucous mem- 
branes (renal, vesical, gastric, intestinal, nasal), and from the 
skin, ears, or anterior chamber of the eye. It is difficult 
to say whether these are results or causes of the amenorrhea, 
as they do not appear at strictly periodic intervals. 

y. Periodic exanthemata : erythematous, impetiginous 
(especially at the edge of the lip), and pustular (acne). 

d. Periodic neuroses : neuralgia, palpitation, cerebral 
congestion, dyspnea (asthma uterinum), cough (tussis 
uterina), gastric colic, digestive disturbances, etc. 

Treatment. — For the vicarious hemorrhages : hot irri- 
gations, scarification of the vaginal cervix ; for the acne : 
Lassar's paste, 1 sulphur ointment, pills of ichthyol (1J 

1 See *• Therapeutic Table." 



42 ANOMALIES OF MENSTRUATION. 

gr. in lozenges) ; for the urticaria and erythema : laxa- 
tives, salicylated alcohol, five per cent, menthol spirit, 
atropin, sodium salicylate (1 J— 2 drams daily) ; for the 
impetiginous eczema (pustules with honey-yellow crusts) : 
diachylon ointment 1 or bismuth salve ; for the herpes : 
zinc oxid ointment ; for the neuralgia and asthma : caf- 
fein, antipyrin, inhalations of chloroform, infus. digitalis, 
and ice-bag over cardiac region. General nerve tonics 
and hydrotherapy are indicated. 

8. Dysmenorrhea is characterized by violent pains 
(causing reflex hemicrania, nausea, vomiting, dizziness, and 
hysteric symptoms), which emanate from the uterine and 
paracervical ganglia, and are to be looked upon as symp- 
toms from the lumbar cord. Other diseased organs (liver, 
heart, lung, stomach) participate in the disturbances. 

From an etiologic standpoint seven forms may be 
differentiated : 

(a) Reflex, from diseased ovaries, tubes, perimetrium, 
etc. 

(6) In the initial stage of intramural myomata. 

(c) So-called neuralgia uteri, with spasmodic flexion of 
the uterus (author) from fright, interrupted coitus, mas- 
turbation, thermic and mechanical insults, acute colds. 

(d) Congestive, with flexions of the uterus and all con- 
ditions that occasion a hyperemia of the organ and its 
ligaments. The pain precedes the flow r and ceases with 
its onset, when the blood-vessels are relieved. 

(e) Inflammatory, with endometritis, metritis, parametri- 
tis, and perimetritis. The pain is most severe at the 
beginning of the period and gradually abates ; the uterus 
is very sensitive, sometimes spasmodically contracted. 
When the congestive (d) and inflammatory (e) dysmenor- 
rheas have reached their height, shreds of mucous mem- 
brane, sometimes the entire mucosa, may be cast off 
(decidua menstrualis). This condition is designated as 
dysmenorrhoea membranacea with endometritis exfoliativa. 

(/) Obstructive, often a result of c and d (see also §§3 



DYSMENORRHEA. 43 

and 4, amenorrhea), or arising from too rapid or too pro- 
fuse a secretion of blood, stenosis or flexion of the cervix, 
or swelling of the endometrium. The pains follow the 
onset of the menses, and resemble those of labor. Large 
clots or shreds of mucous membrane are sometimes dis- 
charged. 

(a) Exfoliatio mucosae menstrualis or dysmenorrhea 
membranacea ivithout endometritis. 

Diagnosis and Treatment. — Indicated under the cor- 
responding letter. 

(ci) In every case of dysmenorrhea the constitution of 
the patient should be considered, and the exact condition 
of the entire genital apparatus should be determined by 
bimanual palpation and, if necessary, by exploration with 
the sound. 

(6) It is impossible to diagnose small intramural mvo- 
mata before they cause a projection of the uterine wall or 
a change in its consistence. The characteristic symptoms 
are violent, fixed, boring pains, without fever. These 
are controlled by suppositories, vaginal or rectal injec- 
tions, or pills of chloral, or by use of extract of bella- 
donna or hyoscyamin, tincture of opium, or antipyrin. 
Rubefacients (sinapisms, menthol, or spirits of camphor on 
compresses), ergotin, and salt baths are useful in the 
treatment of this condition. The patient should rest in 
bed during the attack. 

(c) Potassium bromid, caffein, sodium benzoate, phenac- 
etin, antipyrin (also as a wash), fluid extract of viburnum 
prunifolium, potassium permanganate (to be taken one 
week before the period), and the pills and rubefacients 
previously mentioned. Diaphoresis should be encouraged. 

(d) Rest in bed, warm clothing, especially over the 
abdomen, hot sand-baths, rubefacients (see 6). Laxatives 
and ipecac to prevent overfilling of the stomach, anti- 
monials and diaphoretics for the catarrh. Local depletion 
of the blood-vessels by scarifications, two leeches to the 
cervix, copious hot vaginal injections, or glycerin and 



44 ANOMALIES OF MENSTRUATION. 

astringent tampons. Any existing cause should be appro- 
priately treated : flexions, by pessaries, massage, etc. ; 
stenosis, by dilatation. 

(e) Removal of the inflammation. Treatment of attack 
as in d ; above all, blood-letting (two leeches) and laxa- 
tives, scarifications of the cervical mucosa, wedge-shaped 
excisions (see Metritis), atmocausis (vaporization, see 
Endometritis). 

(/) See treatment of stenosis and amenorrheas in 
§§3 and 4. 

(g) According to v. AVinckel, the application of two 
leeches to the cervix at repeated intervals prevents the 
casting off of the decidua menstrualis and allows concep- 
tion and recovery to take place. Curetment and applica- 
tion of zinc chlorid (chlorid of iron after the operation), 
atmocausis, or zestocausis (see Endometritis). Sympto- 
matic, as under b and d. 

Diagnosis of Exfoliatio Mucosse 3Ienstrualis. — The prodromes are 
sensations of heat and cold, nausea, vomiting, dizziness, headache, 
and unconsciousness, with or without hysteric convulsions. Circum- 
scribed pain in the lower abdomen. The discharged blood may be 
small in amount. 

The membrane is passed with or without pain. If complete, it 
has a triangular shape, showing the position of the three uterine ori- 
fices (ostia tubarum, os internum). The outer surface is rough and 
tattered, having been torn from the uterine wall ; the inner surface is 
smooth, offering for inspection furrows and minute glandular orifices. 

3Iicroscopic Structure. — The connective tissue is increased, and its 
interstices are filled with exudate and small round cells, which push 
apart the utricular glands. The latter are seen in cross-section, with 
their cylindric epithelium and blood-vessels. Larger cells rarely ap- 
pear, and then are quite isolated. The picture is practically that of 
interstitial endometritis. Lohlein points out that pieces of mucous 
membrane obtained by curetment between two periods show none of 
the foregoing changes. 

Membranes are sometimes cast off from the vagina in colpitis exfoli- 
ativa, consisting of polygonal squamous epithelial cells with relatively 
large vesicular nuclei. Similar membranes may be exfoliated from a 
changed epithelial layer of the lower portion of the cervix. (See 
Plates 28 to 31.) 

Microscopic Differential Diagnosis. — The decidua vera graviditatis 
consists of a layer of large, irregular, roundish (decidual) cells pos- 
sessing large nuclei (often multiple). These completely conceal the 
scanty connective-tissue framework. 



3IEX0BBHAGIA. 45 

g. Menorrhagia. — By this term we designate those 
uterine hemorrhages that are so profuse in proportion to 
the general constitution of the individual that symptoms 
of anemia appear, or, if already present, become exagger- 
ated. Its manifestations are dizziness, unconsciousness, 
ringing in the ears, flickering of objects before the eyes, 
nausea, vomiting, constipation, a striking pallor of the 
mucous membranes, lassitude, pain in the back, shortness 
of breath, palpitation, etc. The monorrhagia may be 
habitual or temporary. 

Etiology. — (a) Diseases of the genitalia : tumors, dis- 
placements and inflammations, swellings of the endo- 
metrium ; (b) diseases of other organs that cause circu- 
latory disturbances (heart, lungs, kidneys, spleen, liver) ; 
(c) associated with intestinal diseases (dysentery, consti- 
pation) ; (c/) nervous hyperemia (emotion, hot drinks) ; 
(e) associated with constitutional diseases (Werlhof's 
disease, excessive development of the panniculus adi- 
posns). 

Treatment. — Symptomatic — rest in the horizontal posi- 
tion, a bland diet, soothing drinks (acids, effervescing 
powders), hot fomentations of alcohol, sinapisms. 

Group a: See treatment of endometritis (especially 
the fungous and hemorrhagic forms), chronic metritis in 
the stage of engorgement, parametritis and perimetritis, 
fibroid and mucous polyps of the uterus, sarcoma and 
carcinoma, ovarian tumors, flexion and prolapse of the 
uterus. 

If radical treatment is not adopted, the hemorrhage is to 
be controlled by ergotin, cornutin, secale cornutum, or hv- 
drastis canadensis (hydrastin), stypticin, hot vaginal irriga- 
tions (113° to 125° F.) at intervals of from three to six 
hours, very firm tamponade of the vagina (iodoform gauze 
or salicylated cotton), or even tamponade of the cavity of the 
uterus with iodoform gauze or laminaria. The solution of 
ferric chlorid may be applied upon cotton, as a direct local 
hemostatic, or the medicated sound (aluminum or wood) 



46 ANOMALIES OF MENSTRUATION. 

may be introduced into the cervix and allowed to remain 
there for from two to three hours. Ferripyrin has proved 
itself to be of value, controlling the hemorrhage and pro- 
ducing no irritation. It is used as a powder or, better, as 
sterilized " nondraining ferripyrin-nosophen gauze." x 
Injections of gelatin solution and atmocausis (see treatment 
of endometritis hemorrhagica) are to be recommended. 2 

Group b : Digitalis, expectorants, and the waters of 
Karlsbad, Franzensbad, Kissingen, Wildungen, Neu- 
enahr, and Vichy have a specific action. 

Group c : Laxatives (enemata of infusum sennge, strong 
infusions of rhubarb, 10 : 100, oleum ricini). 

Group d : Arrest hemorrhage as in group a ; ergotin ; 
reduction of obesity by the methods of Banting, Mendelsohn, 
Epstein, or Oertel ; sojourn at Marienbad ; and vegetable 
diet. In hemophilia and scurvy, hydrotherapy and sub- 
cutaneous injections of gelatin. Calcium hypophosphite 
by the mouth or rectum. 

I 5. STERILITY. 

The causes of sterility may be found in the physical or 
psychic nature of the husband or wife, or in the habitual 
disease of the product. They may be divided into four 
groups : 

1. Impotentia coeundi from organic defects or from nervous or 
ps} r chic influences. 

Husband. Wife. 

Epispadias and hypospadias ; par- Atresia or stenosis of the hymen 

esis and paralysis of the nervi or vagina ; vaginismus ; ob- 

erigentes from psychic influence structing tumors or inflamma- 

or nervous weakness (affections tions ; absence of sexual desire. 

of the brain and spinal cord, 

age, perverted habits, etc.) ; 

aspermatism from cicatricial 

stenosis ; prostatic hypertrophy. 

1 Prepared under the author's direction by Evens and Pistor, of 
Cassel. 

2 A complete report of the indications for these new methods of 
hemostasis and results of their application is to be found in the 
author's article in the June number of " Deutschen Praxis," 1899. 



EXAMINA TION—TBEA TMENT. 4Ti 

2. Azoospermism or arrested formation of the genital cell. 

Husband. Wife. 

Atrophy of the testicles (from The Graafian vesicles fail to rup- 

gonorrhea, orchitis, trauma, ture, either from congenital or 

and like causes) ; atresia of the inflammatory causes ; ovarian 

ejaculatory duct. tumors. 

3. The spermatic filament is deposited in the female genitalia but 
is unable to come in contact with the ovum. 

Atresia or stenosis of the uterus 
or tubes (flexions of both), cer- 
vical plugs of tough mucus 
(endometritis) ; uterine or tubal 
tumors ; perioophoritic pseudo- 
membranes. 

4. The ovum fails to lodge in the uterine mucosa. 

Endometritis ; uterine tumors ; 
weakness ; diseases of the ovum. 

Examination. 

Husband. Wife. (See 55 1 to 4.) 

Since gonorrhea is a frequent cause Character of the menses ; presence 
of azoospermism and cicatricial of fluor albus (genococci) ; 

stenosis, the previous history is uterus, by speculum and sound ; 

to be carefully considered and uterus and adnexa, bimanual, 

the number of well-formed sper- 
matic filaments in the semen is 
to be determined. 

The treatment depends upon the cause demonstrated. If no reason 
can be found, advise the patient to hold the semen in the vagina as 
long as possible (with the knees together), as Marion Sims proved that 
the posterior vaginal vault acts as a seminal receptacle, the intra vaginal 
cervix (in the normal position of the uterus) being here bathed in 
the spermatic fluid. In some cases coitus must be practised with the 
pelvis of the female elevated, or a posterioribus. 



GROUP II. 
CHANGES OF SHAPE AND POSITION. 



CHAPTER I. 

HERNIA. 

The abdominal organs may be invaginated into natural, 
preformed canals, — being covered by the enveloping soft 
parts, — and may present themselves in the abdominal 
wall, in the gluteal region, in the course of the femoral 
vessels, in the vagina, or in the labia. For vaginal hernia 
see also Inversion of the Vagina, § 7. 



| 6. HERNIA AND OTHER CHANGES OF SHAPE OF THE 

VULVA. 

The hernial contents may consist of the uterus — espe- 
cially one horn of a uterus bicornis — and its adnexa 
(ovary, see § 1, Pseudohermaphroditism), with or without 
the intestine and its appendages, or of the intestine alone. 

The more frequent path is through the inguinal canal 
(Fig. 23) ; less often in front of the broad ligament and 
along the levator ani. In the first case we speak of a 
hernia inguinalis labialis (anterior) ; in the latter, of a 
hernia vaginalis labialis (posterior). The hernia may 
attain the size of a melon. 

Diagnosis. — Varying changes of size of the tumor, 
reduction of contained intestine (usually filled with gas 
and fluids) with a " gurgle/' the characteristic form and 

48 



TREATMENT. 49 

sensitiveness of the ovary, impulse on coughing, etc., all 
establish the nature of the swelling. 

Treatment. — Just as in other hernias — taxis and 
retention by a truss (Scarpa) or by a large, hollow, vagi- 
nal ring (hard-rubber). If reduction is impossible, open 
the sac and replace, or an abdominal section may be per- 
formed, the hernia reduced, held by fixation sutures, and 
the orifice closed. 

Other changes of shape are seen in the duplication 
and enlargement of individual parts — the nymphae and 
clitoris — which may give rise to irritation, excoriation, 
edema, etc. 

Treatment. — Frequent washings, using astringents if 
necessary, and applications of oak-bark decoctions or 
lead water, constitute the preventive treatment. Boric 
ointment or bryolin, sitz-baths with bran, dermatol, bis- 
muth-talc, nosophen-starch, or applications of solutions 
of cocain are to be used for their curative action. 



CHAPTER II. 

INVERSION AND PROLAPSUS. 

These conditions hold a certain mutual relation, inas- 
much as the former is a weighty predisposing cause of the 
latter. The inverted vagina easily drags the uterus to 
the vulva, while in other cases the inversio vaginae and 
the prolapsus may be traced to a common cause. On the 
other hand, the uterine prolapse, or apparent prolapse, due 
to hypertrophy of the cervix, may lead to protrusions of 
the vaginal mucous membrane. 



i 7. THE INVERSIONS OF THE VAGINA AND UTERUS. 

Inversions of the lower half of the vagina mostly lead 
to the formation of hernias ; the most frequent are those 
of the posterior wall of the bladder (Cystocele, Plate 5, 
Fig. 1) and of the anterior wall of the rectum (Rectocele, 
Plate 5, Fig. 2). The upper half of the vagina is far 
less often the seat of inversion, the other organs carrying 
the rectovesical or vesico-uterine folds of peritoneum 
ahead of them. In the " Atlas of Obstetric Diagnosis 
and Treatment" (Figs. 102 to 105) cases of incarcerated 
retroflexed gravid uteri and of extra-uterine pregnancy 
are illustrated in which the gestation sac causes a protuber- 
ance of the vaginal wall. 

Among the rarer cases brought to our notice are ovario- 
colpocele, enterocolpocele (Plate 19, Fig. 1), hydrocolpo- 
cele, pyocolpocele (Plate 58, Fig. 1, and Plate 59, Fig. 3), 
and those bulgings of the vaginal wall that are brought 
about by tumors of Douglas' pouch (Plates 58 and 59), or 

50 



VAGINAL INVERSION. 



51 



of the rectovaginal or vaginovesical septa. (Plate 58, 
Fig. 3 ; Plate 88, Figs. 5 and 6.) 

If the ovary, intestine, or omentum becomes fixed in 
the pouch of Douglas, it may cause the vaginal wall to 
bulge, so that in extreme cases it presents itself at the vul- 




Fig. 23. — Inversion of both vaginal walls and inguinal hernia of 
the right labium in a case of lacerated perineum (photograph of an 
original water-color). The two conditions are not infrequently associ- 
ated, as they have a common cause — relaxation of the supporting 
tissues. 



var opening. This is particularly true in cases of retro- 
flexion or prolapse of the uterus. The simultaneous in- 
version of the anterior and posterior vaginal walls is rare, 
because it could be caused only by an influence exerted at 



52 VAGINAL AND UTERINE INVERSION. 

the same time on both recto-uterine and vesicouterine cul- 
desacs. It is rarely caused by ascites (with a retroflexed 
or vertical uterus), more frequently by pus or an encap- 
sulated peritoneal exudate (pyocolpocele). 

Diagnosis. — See scheme and differential diagnosis of 
tumors of the recto-uterine pouch, § 35. 

In ovariocele bimanual exploration reveals a charac- 
teristic form, sensitiveness, and relation to the tube and 
uterus. If the ovary is enlarged or embedded in exu- 
date, other differential points must be considered (explora- 
tion per rectum). 

Enterocele is recognized by the signs common to all 
intestinal hernias, palpable and audible gurgling and 
changes in the tension of the tumor, with variations of 
intra-abdominal pressure (impulse on coughing). 

Hydrocolpocele and pyocolpocele are to be suspected if 
the symptoms of ascites and peritonitis are present. (See 
Peritonitis.) Carefully examine the previous history. 

Prognosis and Treatment. — An enterocele can be- 
come troublesome only during delivery. Reduction from 
the rectum if necessary ; colporrhaphy, in some cases 
during pregnancy. 

A displaced ovary should be reposited, the patient be- 
ing in the lateral or knee-chest posture (narcosis if neces- 
sary, finger in rectum). The difficulties encountered are 
dependent entirely upon the number of adhesions. The 
reposition of ovarian tumors during pregnancy or labor 
may lead to serious consequences. If it fails, the tumor 
must be tapped from the vagina. 

The prognosis and treatment of hydrocolpocele and 
pyocolpocele are the same as those of the causative disease. 
Puncture from the vagina if condition is analogous to 
cases just mentioned. 

Inversion of the posterior vaginal wall may lead to 
rectocele. As the two organs are connected only by loose 
connective tissue, this displacement does not always 



UTERINE INVERSION. 53 

occur ; indeed, the rectum generally induces it. As usual 
causes may be mentioned relaxed vaginal walls, gaping of 
the vulvar cleft, with or without perineal laceration, and 
prolapse of the uterus. It presents itself to the examin- 
ing finger as a pocket, which causes constipation and 
tenesmus. (Plate 4, Fig. 1 ; Plate 5, Fig. 1 ; Fig. 27.) 

The treatment consists in the repair of the perineum 
and pelvic floor and in the shortening and narrowing of 
the vagina. (See operations described under Prolapse of 
the Uterus.) When the muscular coat of the vagina is re- 
laxed from colpitis : astringents, either as injections (solu- 
tions of aluminum acetate, 10 to 20^) or upon tampons 
(glycerite of tannin). A pessary should be looked upon 
as a temporary makeshift. 

Inversion of the anterior vaginal wall is more fre- 
quently by far associated with cystocele, because the two 
organs are firmly connected, and the intra-abdominal ten- 
sion causes the bladder to follow the vaginal wall. The 
bladder is divided into two pouches, one lying behind the 
pubic symphysis, the other in the cystocele. The latter 
draws the urethra down with it, causing it to assume an 
S-shape. The greater concavity looks downward and 
leads into the cystocele. (Plate 4, Figs. 2 and 3 ; Plate 
3, Fig. 5 ; Plate 5, Figs. 2 and 4 ; Plates 8 and 9, Cath- 
eterization ; Plate 12; Plate 13, Condition in Artificial 
Prolapse.) The disturbances of the circulation in the 
inverted parts sometimes cause dysuria, and, together with 
the inability completely to empty the bladder, may lead 
to cystitis and to the formation of vesical calculi. 

Treatment. — Plastic operations to narrow the anterior 
vaginal wall and to retain the bladder and the vaginal 
wall in their proper places. 



INVERSION OF THE UTERUS. 

This is an affection, severe in its nature, arising under 
quite similar circumstances. The chief etiologic factor is 



54 VAGINAL AND UTEEINE INVERSION. 



PLATE 3. 

Fig. 1.— Impressio fundi uteri as an initial stage of inversion of 
the uterus arises when the organ is relaxed, and Crede's method is too 
forcibly exercised, or traction is made upon the cord. 

Fig. 2.— Partial Inversion of the Uterus. A portion of the 
cervix has not yet become invaginated. The inverted uterus already 
forms a considerable peritoneal pocket ; this ; ' funnel " is filled by the 
tube and ovary. 

Fig. 3. — The uterus has become invagiuated as far as the external 
os ; the latter, however, has not descended. 

Fig. 4. — The completely inverted uterus protrudes from the vulva ; 
the upper portion of the vagina has also become invagiuated as far as 
the constrictor cunni and levator ani. 

Fig. 5.— Complete Prolapse of the Retroflexed Uterus and 
of the Vagina with Laceration of the Perineum ; Cystocele. 
(See Fig. 28 and Plates 8-10.) The apex of the bladder approaches 
the fundus ; the vesical diverticulum reaches to the internal os ; the 
pouch of Douglas lies in the prolapse, containing, however, no intestinal 
loops (enterocele), as sometimes occurs in rare cases ; the intestines are 
held back by the retroflexed corpus uteri. The external os is everted ; 
the cervix is swollen. 

This illustration represents one of the extreme possibilities of pro- 
lapse, and at the same time the most frequent manner of its develop- 
ment. 



a relaxation and dilatation of both the uterine and cervical 
walls. The direct cause is most frequently an acute one, 
occurring in the puerperium (precipitate birth, forced 
Crede's method, traction on the cord) ; or one chronic in 
its nature, such as traction upon the fundus uteri from the 
expulsion of a fibroid polyp. If the tumor is submucous, 
the mucous membrane alone is drawn down ; if it is intra- 
mural, the muscular coat, or even the serous covering, may 
be invaginated, so that a peritoneal " funnel " is formed in 
which the adnexa or intestinal coils (only in puerperal 
inversions) may lie (Kehrer). The latter may contract 



Tab. 3. 



&> r 




Tigl. 




Fig. 2. 




Fig.J. 




Fig. 4 . 




Fig, o. 



Lith.Artst. F Reichhold. Munclien . 



UTERINE INVERSION. 55 

inflammatory adhesions in cases of lone standing. (Plate 
3, Fig. 2; Fig. 24.) 

Different degrees of inversion may be differentiated : 
complete, including the entire cervix ; complete, with in- 
version of the vagina (inversio uteri cum prolapsu) ; in- 
complete, as far as the internal os. The slightest degree 
is the impressio fundi uteri, (Plate 3.) The acute puerperal 
inversion may become chronic. 

Symptoms. — The mucosa swells and proliferates from 
the constriction. It bleeds easily, and ulcers arise from 
friction. The ulcerated surfaces may grow fast to the 
vaginal mucosa, or gangrene may appear. The acute 
puerperal form occurs with violent symptoms resembling 
shock. 

The chief symptoms are pain and hemorrhage, de- 
pendent upon the nature of the tumor. They render the 
patient anemic and force her to stay in bed. 

Diagnosis. — An exact portrayal of the existing condi- 
tions is demanded, as an inverted uterus has been repeat- 
edly confounded with a polyp, and cut off. 

In complete inversion with prolapse we find a red, solid- 
elastic tumor, which bleeds easily and is sensitive to pres- 
sure. The uterine orifices of the Fallopian tubes may 
probably be recognized. 

In incomplete inversion the sound may be passed into 
the cervix, beside the tumor (corpus uteri), for quite a 
distance — further in front than behind (from 3 to 4 cm.). 
Bimanual palpation is of importance ; it demonstrates the 
absence of the uterus from its usual position and the pres- 
ence of the peritoneal " funnel." 

Treatment. — If due to a tumor, enucleation of the 
same, whereupon the uterus usually reinverts itself spon- 
taneously. If irreducible from proliferative thickening of 
the uterine wall, amputation of the organ close to the 
external os, carefully closing the peritoneal funnel with 
sutures. In acute puerperal inversion, manual reposition 
(as in phimosis), trying to push back the portion in con- 



56 VAGINAL AND UTERINE INVERSION 

tact with the external os first, and making counterpressure 
from the abdomen to prevent elongation and possible 
laceration of the vagina. 

The earlier the attempt is made, the more likely is it to 
be crowned with success. If manual reposition fails, the 
parts are to be carefully disinfected and pushed back by 




Fig. 24.— Complete inversion of the uterus from a myoma of the 
fundus. (See Plate 3.) (Original diagrammatic drawing.) 

the colpeurvnter (always to be filled after introduction) or 
by means of astringent tampons. These are held in posi- 
tion until the tumor is partly reduced, when the reinver- 
sion is completed by cold-water injections. Massage of 
the uterus assists the action of the colpeurynter, and ergot 



VAGINAL AND UTERINE PROLAPSE. 57 

effects the contraction of the organ. Elevations of tem- 
perature give warning of the onset of pelvic peritonitis, 
when all attempts at reduction must be discontinued. 

Celiotomy is indicated only in extreme cases. A better 
method is that of KiAstner, who makes an incision in the 
posterior vaginal vault, which enables him to incise the 
posterior uterine wall throughout its entire length, and to 
rein vert the organ. Kehrer attacks the uterus through 
the anterior vaginal vault. 



?8. PROLAPSE OF THE VAGINA AND UTERUS. 

When the external os sinks below the interspinous 
plane, we speak of descensus uteri. If in addition to 
the descent of the uterus the lower portion of the vagina 
protrudes at the vulva, the case is one of incomplete or 
partial prolapse of the vagina ; if the vaginal vault also 
protrudes, complete prolapse. 

In incomplete prolapse of the uterus the cervix alone 
protrudes at the vulva ; in complete prolapse the en- 
tire organ — with the completely inverted vagina, and 
cystocele or rectocele, or both — lies outside of the introitus. 

The Normal Situation and Position of the Uterus. 

The normally situated uterus lies in the true pelvis in a position of 
anteversion. The anterior surface is obliquely placed, lacing the 
bladder ; the posterior surface is strongly convex, and is parallel to the 
upper sacral curvature. The longitudinal axis of the organ passes 
from above downward, and from before backward. If fixed points 
are desired, the fundus marks the center of the conjugate vera, and 
the external is in the interspinous plane, being somewhat nearer to 
the sacrum than to the symphysis. (Plates 14 and 22.) 

This position is not a constant one, however ; the uterus is in a 
condition of unstable equilibrium, the fundus descending with every 
inspiration. In the upright position the fundus is still lower, while 
the cervix becomes more elevated. It is balanced upon an axis of 
fixation corresponding to the internal os, this portion of the neck 
being suspended from the pelvis and sacrum by the supravaginal con- 
nective tissue and the involuntary muscle-fibers of the uterosacral 
ligaments. In the dorsal position the fundus goes backward and the 
cervix approaches the symphysis. The position is also dependent upon 



58 VAGINAL AND UTERINE PROLAPSE. 



PLATE 4. 

Fig. 1. — Incomplete Prolapse of a Retro verted Uterus; 
Marked Rectocele ; Vaginal Inversion. 

Fig. 2. — Incomplete Prolapse of the Uterus, Due to Hyper= 
trophy of the Intermediate Portion of the Neck ; Inversion of 
the Vagina with Cystocele. (See Plate 12.) The fundus of the 
uterus is nearly at its normal height. The sound shows the uterine 
canal to be longer than normal (longer than 5 or 6 cm.). The distance 
from the internal to the external os demonstrates the elongation to be 
in the intermediate portion of the cervix. The portion of the neck 
that is elongated is further shown by the relation of the anterior 
and posterior vaginal fornices to the external os and to the internal os. 

The illustration shows the posterior vaginal vault at its usual 
height in the pelvis ; the anterior, however, is lower, and yet holds its 
usual relation to the external os ; consequently, it is not the intra- 
vaginal cervix that is hypertrophied, but the middle portion of the neck, 
situated between the anterior and posterior vaginal fornices and lying 
higher up. 

Fig. 3— Total Prolapse of Anteflexed Uterus and of the 
Anterior Vaginal Wall, with Cystocele ; Characteristic Flexion 
of the Urethra. (See also Plates 8 and 9, Introduction of Catheter.) 

Fig. 4.— Complete Prolapse of Retroflexed Uterus (First 
Degree) and of Vagina. Small rectal and vesical diverticula. 



PLATE 5. 

Fig. 1.— Prolapse of Posterior Vaginal Wall; Rectocele; 
Descent of Retroflexed Uterus (Second Degree). The posterior 
vaginal wall seldom becomes inverted first ; a rectal diverticulum may 
form in the pouch, demonstrable to the introduced finger. 

Fig. 2. — Prolapse of the Anterior Vaginal Wall ; Extreme 
Grade of Cystocele ; Anteflexion of the Uterus (First Degree); 
Descent of the Uterus. Evidence of the existence of a cystocele 
is obtained by the catheter. (See Plates 8 and 9.) 

Fig. 3. — Reposition of Prolapsed Uterus by a Martin Stem= 
pessary. (Original diagrammatic drawing, modified according to 
Schroder. ) This pessary is applicable when the genitalia are room} r or 
relaxed. The stem rests upon the levator ani, receiving lateral sup- 



^ 















*2 



*6 




I 

§ 





UTERINE SUPPORTS. 59 

port if it slips to one side. This case is one of pseudoprolapse, 
because the reposition nuduly elevates the fundus, anteflexes the body, 
and draws up a diverticulum from the bladder. The condition is 
really elongation of the neck, and amputation is indicated. 

Fig. 4.— Hypertrophy of the Anterior Lip of the Uterus, 
Producing Inversion of the Anterior Vaginal Wall and Cys= 
tocele. (Original diagrammatic drawing modified according to 
Schroder.) 

the degree of distention of the bladder and rectum. (See \\ 10 and 
11, Plate 17, Fig. 2 ; Plate 14, Figs. 1 and 4 ) 

The uterus is not really " suspended," but the ligaments limit the 
excursions of the organ beyond a certain point. It really rests indi- 
rectly upon the floor of the pelvis, the external os pressing against the 
posterior vaginal wall, and the cervix being grasped by the connective 
tissue surrounding the vaginal vault. The latter is partly held up by 
ligaments, but more particularly by the vaginal walls themselves, 
these in turn deriving their support from the pelvic floor (con strict ores 
cunni, levatores ani) and perineum. The integrity of the perineum 
is consequently a most important factor in preventing the descent of 
the internal genitalia, the ligaments being a secondary consideration. 
It is not to be forgotten that the uterine supports may be insufficient 
to withstand an increased pressure from above (tumors) or traction 
from below. These structures are assisted by atmospheric pressure 
when the patient is in the knee-elbow position, and Sims' speculum 
is introduced. The round ligaments resemble a bridle, having no 
supportive action. 

The size of the uterus also influences the existing conditions. 

The recto-uterine fold of peritoneum is normally 7 cm. above the 
anus ; the vesico-uterine, lh cm. above the urethral orifice. Note the 
following measurements : 

Length of the uterus (external measurement) : 

In virgins 6-8 cm. ; weight, . . 40 gm. 

In married women . . 8-10 " u . . 100 u 

Width : 

f^ e 4/. /. -, f in virgins 4-5 cm. 

Ox the fundus { . te . -, rl nl u 

tin married women .... 5^-6^ 

Of the neck 2 -2| " 

Thickness t^™gms 2 -3 » 

(in married women .3 -3 J 

Length of uterine cavity : 

Entire. 

In the immature uterus 2.6 

In the mature virginal uterus . . . .5.4 
In the uterus that has been gravid . .5.9 
The corporeal secretion of the uterus is thick and oily ; the cervical, 
albuminoid or mucoid. Both are alkaline and contain mucin (coagu- 
lated by acetic acid). 



Body. 


Neck. 


0.8 


1.8 


3.2 


2.2 


3.3 


2.6 



60 VAGINAL AND UTERINE PROLAPSE. 

The prolapsed mucous membrane of the vagina and 
vaginal cervix becomes either excoriated (Plates 8 and 
10) or covered with a thickened layer of epithelium, the 
superficial strata of which are horny in character. (Plate 
28, Fig. 2.) The lips of the cervix are everted. (Plates 
10 and 12, Figs. 28 and 29.) The introitus vaginae 
(about 1 or 2 cm. of the vagina) maintains its normal 
position, even in extreme cases, forming a swollen ring 
about the prolapsed tumor. The latter consists of the 
vagina and uterus, and contains diverticula from the 
bladder and rectum. (Plates 10 and 13.) The urine 
(or fecal matter) stagnates in these pouches, inducing 
catarrh and the formation of calculi ; especially as the 
urethra is usually sharply bent upon itself. If the lower 
and posterior half of the bladder forms the diverticulum, 
the ureters are likewise bent at an acute angle and may 
give rise to hydronephrosis. (Plate 4, Fig. 3 ; Plate 5, 
Fig. 2 ; Plate 12.) Retroversion of the uterus acts as a 
predisposing cause for this condition of affairs (and for 
prolapse generally), especially when it is combined with 
laceration of the perineum (loss of support for vaginal 
wall) or descensus uteri. (Plate 4, Fig. 1 ; Plate 5, 
Fig. 1 ; Plate 13 ; Plate 19, Fig. 1.) Even the apex of 
the bladder and the vesico-uterine fold of peritoneum may 
be in the tumor. As the pouch of Douglas is in close 
contact with the posterior vaginal vault, it is likewise 
well down in the prolapse, and may accommodate a loop 
of intestine. (Plate 4, Fig. 4 ; Plate 13.) 

The development of the prolapse is as follows : 
The anterior vaginal wall loses its normal support, either 
from perineal laceration (Plate 54) or from weakness of 
the pelvic floor. (Plates 6, 7, 25, 27.) The tuberculum 
vaginae sinks down first, and remains between the nymphae. 
Then the upper portion of the vagina begins not only to 
descend, but also to invaginate itself, as may be demon- 
strated every time the patient bears down. The cervix 
of the still normally anteverted uterus is drawn downward 



BE VELOPMENT. 6 1 

and forward. (Plate 54, Figs. 2 and 3.) By this time 
the posterior vaginal wall commences to prolapse, making 
traction upon the posterior vaginal vault and, through it, 
upon the uterus. (Plate 54, 4.) This organ assumes 
first a vertical position, and then one of retroversion, its 
long axis running parallel with that of the vagina, which 
is now more vertical. At this time the slightest sudden 
pressure from above, a fall, or a series of similar factors 
acting in a like manner is sufficient to effect prolapse of 
the uterus. (Fig. 26.) The same pressure from above, 
together with the usually existing relaxed uterine wall, 
causes a bending of the body toward the cervix — retro- 
flexio uteri. The relations of the bladder and peritoneal 
folds are shown in plates 4 and 5, and in figures 27 and 
28. 

If the prolapse is complete, the pressure acts still 
further, everting the cervical mucosa (in extreme cases as 
far as the internal os), which swells and becomes eroded. 
(Plates 8, 10 ; Fig. 28.) A lividity of the cervix results 
from the circulatory disturbances. (Plate 10.) In chronic 
cases this congestion leads to inflammation and prolifera- 
tion ; giving rise not only to polyps of the mucous mem- 
brane, but also to secondary enlargements and elongations 
of the uterine neck — elongatio colli. (Plates 4, 5, and 12 ; 
Fig. 25.) 

The body of the uterus takes little part in the process. 
The superficial epithelial layer becomes horny. (Plate 28, 
2.) The muscular coat of the vagina becomes thickened, 
and the adipose tissue disappears. 

Symptoms. — When the patient stands or walks, she 
feels as though the descending organ would fall out ; if the 
prolapse is complete, it impedes her movements ; it be- 
comes ulcerated and painful from rubbing — the same is 
true of the thigh. The vaginal and cervical mucosae be- 
come inflamed, not only secreting mucopus, but causing 
profuse and painful menses. The prolapsed parts are 
much enlarged — at first from stasis, later from prolifera- 



62 VAGINAL AND UTERINE PROLAPSE. 

PLATE 6. 
Inversion of the Posterior Vaginal Wall. Leukorrhea ; in- 
tact perineum. (Original water-color.) 

tion of the connective tissue. (Chronic Metritis, Plates 28 
and 32.) The dragging upon the adnexa calls forth ner- 
vous and dyspeptic symptoms. Defecation and urination 
are interfered with from secondary retention. Aside from 
its subjective discomfort, secondary inflammation of the 
peritoneum, by encapsulating the tubes and ovaries in 
exudate, leads to sterility. Structural changes in the 
uterine mucosa and the difficulties attendant upon cohabita- 
tion and upon retention of the semen are productive of 
the same result. The organs become fixed in their abnor- 
mal position. 

Etiology. — Congenital prolapse of the uterus is one of 
the greatest rarities. I found such a case in a child with 
hydromeningocele at the Munich Frauenklinik (Fig. 25) ; 
I saw a second in the Heidelberg Frauenklinik in 1894. 1 
It is also a rare condition in the virgin, being here caused 
by heavy lifting. The most frequent causes are found in 
puerperal injuries and too early attempts at straining, since 
at this time the uterus already has a tendency to assume 
or maintain a retrodeviation. Severe labors (forceps) lead 
to perineal lacerations and to stretching and relaxation of 
the genital walls and suspensory apparatus. (See explana- 
tions of Plates 13, 17, and 54 ; also p. 57.) 

Retroversion of the uterus is easily produced by puer- 
peral subinvolution with a relaxed vagina, chronic inflam- 
matory conditions, frequent labors in delicate women, and 
tumors that force the uterus downward. Immediately 
after every normal labor the anterior lip of the cervix 
may be palpated, just within the introitus vaginae. 

1 Described in " Arch. f. Gyn." by Dr. Heil. At that time I knew 
of only a third similar case (Qviesling, "C.f. Gyn.," 1890) ; since then 
several have been published. 



Tab. 6. 







PROGNOSIS. —DIA GNOSIS. 



63 



Prognosis. — The danger of acute gangrene from con- 
striction is a remote one. The condition is weakening 
from all the preceding manifestations. The excoriations 
predispose to epithelioma (v. AVinckel). 

Diagnosis. — In many patients the prolapse recedes 
when they lie down or remain quiet ; but any increase of 
the intra-abdominal tension (coughing, lifting, straining at 
stool) causes it to descend, or to protrude from the vulva. 




Fig. 25. — Congenital incomplete prolapse of the uterus from a 
mature fetus with hydromeningocele (Munich Frauenklinik, 1889 ; 
" Arch. f. Gyn.," 37, 2). Hypertrophy of the middle portion of the 
neck ; inversion of the vaginal vault ; marked development of the 
ovarian arteries, with iliac arteries of small lumen. The os is notched, 
and a slight ectropion is present. 

The exact contents of the prolapse must be determined. 
Does it contain the uterus ? How much of the vagina ? 
Are vesical or rectal diverticula present ? A number of 
conclusions may be drawn from inspection. (Figs. 26 to 
29 ; Plates 8 to 10.) The external os, the cervical canal, 
and the length of the uninverted portion of the vagina 
are recognized by exploration with the finger and sound. 



6-1 VAGINAL AND VTERIXE PBOLAPSE. 

PLATE 7. 

Fig. 1. — Inversion of the vagina from a perineal tear of the 
third degree (into the rectum) ; the tuberculum vaginae has descended. 
(Original water-color.) 

Fig. 2. — View of the Cervix in a Case of Elevation of the 
Uterus. The cervix does not present itself as a free projection into 
the vagina, but forms the apex of the vaginal fannel. The oval ex- 
ternal os gapes slightly. 

Palpation from the rectum demonstrates the existence of 
a proctocele and, in doubtful cases, the absence of the 
uterus from its usual position. The direction taken by 
the vesical diverticulum is shown by the catheter. 

If the uterus is completely prolapsed, it may be grasped 
outside of the vulva, and a retroflexed (common), ante- 
flexed, or vertical position may be recognized. (Figs. 26 to 
29.) 

In an incomplete prolapse the differential diagnosis 
from cervical hypertrophy must be made. The dis- 
tance from the external to the internal os is to be meas- 
ured with the graduated sound (the normal uterus has a 
cervical canal 6 cm. long). The internal os is recognized 
by the resistance that it offers to the passage of the 
knobbed tip of the sound. The distance that the ante- 
rior and posterior vaginal vaults extend above the exter- 
nal os is also to be determined. (Plates 12 and 15.) 

Finally, it must be ascertained whether the uterus is 
freely movable in its hernial sac, or adherent to its adnexa 
and to the descended coils of intestine. 

Treatment. — Prophylactic. — Perineal lacerations are 
to be repaired at once. If the puerperal uterus is inclined 
to retrodeviation, keep the patient on her side as much as 
possible. She should never get up before from the tenth 
to the fourteenth day, and if the foregoing predisposing 
causes of prolapse exist, she should be kept in bed for two 
or three' weeks, and then forbidden to lift or to do hard 



GROUP I. 

ANOMALIES OF FORMATION AND 
ARRESTED DEVELOPMENT. 



CHAPTER I. 

FETAL ANOMALIES OF FORMATION. 

The anomalies of formation of the female genitalia are, 
almost without exception, examples of arrested develop- 
ment. The differentiation of the Miillerian ducts is im- 
perfect or does not occur — the customary fusion fails to 
take place, or the ducts unite to form a single tube of 
limited extent. Defects of the entire genital tract or of 
individual organs are thus explained, as are also the con- 
genital atresias, fistulas, and partial or complete duplica- 
tions of the genital tube (Kussmaul). 

The following forms are of clinical importance : 



i i. APLASIA AND HYPOPLASIA OF THE FETAL RUDI= 
MENTS. 

1. Absence of the uterine appendages. 

2. Absence of the uterus. 

3. Absence of the entire genital tract, with or with- 
out — 

4. Pseudohermaphroditism. 

5. Uterus unicornis : i. e., absence of a portion of one 
of the Miillerian ducts (Fallopian tube attached to the 
uterine portion of one Miillerian duct), 

2 17 



18 



AN03TALIES OF FORMATION. 



6. Atresias — which may be cord-like or diaphragmatic 
— in the cervix (corresponding to the internal or external 
os) ; in the vagina, hymen, or vulva. 

7. Congenital rectovaginal or recto vulvar fistulas (atre- 
sia ani vaginalis or hymenalis, cloaca vaginalis, or fistula 
rectovestibularis). 

8. Feminine epispadias and hypospadias. 

i and 2. Total absence of the uterus and its ap- 
pendages is very rare, and usually is first discovered at 
puberty. Solid bundles of muscle-fibers pass up from 




Fig. 1. — The fetal genitalia cut open in a median sagittal plane, so 
that the divided symphysis is thrown hack on either side. Absence 
of the uterus (original drawing, from a preparation in the Munich 
Frauenklinik). 

a rudimentary vagina and through the broad ligament, 
which can be recognized as a small transverse partition in 
the pelvis. The vulva is well developed, as a rule, the 
most striking external defects being a stunted clitoris, ab- 
sence of the pubic hair, and smallness of the breasts. 

The ovaries, on the contrary, are absent or but par- 
tially developed. The Fallopian tubes are patulous only 
in their ampullae. In one case I found at autopsy 1 a 

1 In a fetus at the Munich Frauenklinik, "Arch. f. Gym," 37, 2. 



ABSENCE OF GENITAL TRACT. 19 

total absence of the uterus and its appendages, with an 
elongated vagina. One portion of the fetal rudiments had 
formed this blind pouch, without any attempt at differen- 
tiation of a cervix. (See Fig. 1.) 

Symptoms. — From the fact that the ovaries are absent 
it follows that the sexual instinct is usually wanting, 
although it may be present. The most striking symptom 
of all — nonappearance of the menses at puberty — may go 
hand in hand with the periodic appearance of the men- 
strual molimina. 

Should such individuals indulge in sexual intercourse, 
new troubles arise from the forcible dilatation of the rudi- 
mentary vagina, or frequently of the urethra (incontinence 
of urine sometimes) (Plate 19, Fig. 2), especially since 
the latter often has a funnel shape, owing to a dropping 
back of the posterior wall. 

Diagnosis. — Bimanual examination establishes the ab- 
sence of the uterus. (Plate 19, Fig. 2 ; Plate 21, Fig. 2.) 
The finder is introduced into the rudimentary vagina or 
rectum, and counterpressure is made either through the 
abdominal Avail or by introducing a sound or the finger 
into the bladder after dilatation of the urethra, or by tam- 
ponade of the vagina. The uterus and adnexa are to be 
sought for above the vaginal rudiment. Their recognition 
is by no means easy. 

3 and 4. Absence of the entire genital tract renders 
the individual sexless, and may exist without any other 
malformation sufficient to endanger life. The vulva may 
be entirely wanting or it may be well developed. In a 
case that I saw the latter condition obtained, together 
with a hymen so yielding that it could be pushed in for 
several centimeters. The individual was subsequently 
married to her lover, who was fully cognizant of her 
genital peculiarities. 

The clitoris may be robust ; the labia majora may be 
fused, forming a median raphe ; the nymphse may be de- 
formed ; and the genital fissure may be closed or so short- 



20 ANOMALIES OF FORMATION. 

ened that the case assumes a pseudohermaphroditic char- 
acter. In this event a careful examination will reveal 
genital glands in the labia majora * in fact, the labia 
majora not only resemble the scrotum, but may contain 
testicles. 

This condition is known as pseudohermaphroditism. 1 
If testicles and ovaries are found in the same case, we call 
the individual a true hermaphrodite. No such case has 
been established beyond a doubt. Most pseudohermaph- 
rodites have proved themselves to be males, and some 
of them are capable of procreation, the latter being espe- 
cially true when the genital eminence is well developed 
and the catheter demonstrates a culdesac in the posterior 
urethral wall. Female pseudohermaphroditism is always 
associated with vaginal atresia. 

Treatment. — When the uterus does not exist, the 
attempt to make an artificial vagina is aimless and futile. 
In such a case it is the duty of the physician to explain 
the condition of affairs to the patient and to treat the 
menstrual molimina symptomatically (narcotics and ex- 
ternal derivatives, oophorin tablets, castration). In cases 
of hermaphroditism the predominant sexual type should 
be determined as accurately as possible, since it has fre- 
quently happened that the conjugal relation has been 
assumed and the individual has first become conscious of 
his or her true sex during married life. 

5. Uterus Unicornis. — It sometimes happens that one 
Mullerian duct remains rudimentary or imperfectly differ- 
entiated into its corresponding half of the uterus and 
appertinent tube. This half has a weaker muscular coat 
and the uterus is narrower, pointed, and possesses a horn 
curving toward the better-developed side. (Fig. 2.) The 
mildest degree of this condition is known as uterus inse- 

1 The germinal glands are mostly rudimentary ; the other sexual 
attributes are those of the opposite sex. Gynandres : marked degree 
of male hypospadias, including scrotum ; a stunted penis ; testicle 
still in the abominal cavity or inguinal canal. Viragines : adhesion of 
the labia, enlarged clitoris ; menstrual hemorrhages. 



UTERUS UNICORNIS. 



21 



qualis, and arises from arrested development of one side. 1 
The outcome of pregnancy and labor in such a case is 
portrayed in the u Atlas of Obstetric Diagnosis and 
Treatment" (second edition, Munich). The tube and 
ovary may be absent on the rudimentary side, or there 





V: 




v ^i^^SS- 




I 






I 


#"*,. / j 


X., 


* ****** ... 



Fig. 2. — Uterus unicornis dexter ; left half developed only as an 
elongated tube. Hymen septus (prepared as in Fig. 1). 



may be a longer, undifferentiated tube, which is either 
solid or partly patulous. In such cases the extra-uterine 

1 In two fetal cases I found that the round ligament was not 
inserted into the angle between the uterus and the tube, but radiated 
toward the latter. The broad ligaments and tubes of the two sides 
were of unequal length. 



22 ANOMALIES OF FORMATION. 

transmigration of spermatic filaments or ova has been 
known to occur. 

The early diagnosis of pregnancy is of great import- 
ance, because the rudimentary horn usually ruptures or a 
false diagnosis of extra-uterine pregnancy may be made. 
6, 7, and 8. Atresias may be found in any portion 
of the genital apparatus. These may be explained in 
various ways : 

(a) They represent an arrested development in early 
embryonic life, when the Mullerian ducts are simply solid 
columns of cells. Such atresias are usually cord-like and 
affect a considerable portion of the duct. (See obliterated 

vagina, Plate 19, Fig. 2.) 

(b) The retarded develop- 
ment may occur a little later, 
— from the fourth to the sixth 
week, — and certain invagina- 
tions or openings of one hollow 7 
viscus into another do not 
occur, resulting in atresia 
vulvse, atresia ani, or atre= 
sia urethrse. 

Fig. 3. — Atresia ani ; con- rrn -\n ±- 

genitfl rectovaginal fistula These malformations may 

(above the hymen). occur alone or in combination 

with o t h e r d e velopm e n tal 
errors, such as a persistent cloaca : L e\, that embryonic 
cavity that connects the bladder with the rectum and is 
closed externally. (Fig. 12.) The external opening first 
appears when the rectovesical septum, containing the 
Mullerian ducts, grows down and forms the perineum. 
(Figs. 12 to 16.) Certain atresias combined with con= 
genital fistulas may be traced back to this embryonic 
period — atresia ani with a rectovaginal fistula = atresia 
ani vaginalis. (Fig. 3.) 

Imperfect closure of the primitive urethra toward the 
vagina gives rise to the rare condition known as femi= 
nine hypospadias (to be explained on etiologic and ana- 




ATRESIAS. 



23 



tomic grounds different from those of a similar condition 
in the male). Imperfect closure toward the clitoris — 
feminine epispadias — is still rarer, and is usually asso- 
ciated with a fissured clitoris, a cleft symphysis (pelvis 
fissa), and inversio (ectopia) 
vesicae : i. e., absence of the 
anterior wall of the bladder, 
the posterior wall being 
plainly visible. 

(c) The fistula rectohy= 
menalis or rectovestibu= 
laris (Fig. 6) springs from 
a later period of the em- 
bryonic cycle, and differs 
from the rectovaginal fistula 
in that the opening is in 

the vulva, outside of the hymen. It dates from the forma- 
tion of the perineum (consequently, later than the cloaca), 
which is formed by the union of the septum urogenito- 




Fig. 4. — Hypospadias; posterior 
wall of urethra is wanting. 





Fig. 5. — Epispadias : anterior 
wall of urethra is wanting ; clit- 
oris nssa. 



Fig. 6. — "Recto vestibular or 
rectohymenal fistula with con- 
genital atresia ani. 



rectale with two lateral eminences, which have grown 
down and fused by a perineal raphe. (Figs. 1± to 16.) 

(c?) A fourth group of atresias originates in this fetal 
period, or at a much later one, in the shape of inflamma- 



24 



ANOMALIES OF FORMATION. 



tory adhesions. These are much more likely to assume a 
diaphragmatic character. Examples of these are seen in 
atresias of the vulva and of the hymen and in closure of 




Fig. 7. — Atresia hymenalis, 
hematocolpos, hematometra, an I 
hematosalpinx (both the internal 
and the external os may be rec- 
ognized). 




Fig. 8. — A t r e s i a vaginalis 
from a transverse membrane 
(both the internal and the exter- 
nal os may be recognized). 
Partial hematocolpos, hemato- 
metra, partial hematosalpinx of 
both sides. 



the vagina, of the cervix, and of the uterine orifices by 
transverse bridges of mucous membrane. Atresias may 




Fig. 9. — Atresia cervicalis 
uteri. Hematometra, hemato- 
salpinx (internal os may be rec- 
ognized ; external os free). 




Fig. 10. — Atresia vaginalis 
with uterus and vagina duplex ; 
left-sided partial hematocolpos, 
hematometra, hematosalpinx 
(both the internal and the exter- 
nal os may be recognized). 



also be encountered in cases of uterus bicornis. (Figs. 
7 to 11.) 



ATRESIAS. 



25 




Fig. 11. — Atresia of the ex- 
ternal orifice of a bicornate 
uterus ; left-sided hernatometra, 
hematosalpinx. 



Symptoms. — The symptoms of the genital atresias 
vary, and appear at different periods of life, according to 
their nature. Every new- 
born child should be care- 
fully examined as to the per- 
meability of the urethra and 
anus. This is frequently 
neglected, and anal atresia, 
or even complete closure of 
the urethra, is discovered 
only after days, either by 
accident or through symp- 
toms of retention. 

The hymen also deserves 
attention, for although atre- 
sia in this situation is usually first discovered at puberty, 
there are recorded cases in which the menses had never 

appeared, owing to the pres- 
ence of this anomaly, and 
yet the condition remained 
unrecognized until the 
patient assumed the marital 
relation. The cardinal 
symptom of all genital atre- 
sias, with the exception of 
those cases of uterus bi- 
cornis in which one side 
is patulous, is nonappear- 
ance of the menses. In- 
creasing distention of the 
genital tract by mucus and 
by menstrual blood is the 
cause of the earliest dis- 




Fig. 12. — For the sake of 
simplicity, the two Miilleriau 
ducts are drawn one behind the 
other, instead of side by side. 
They empty into the cloaca, 
which connects the bladder 
(allantois, V) and the rectum 
(B), and which has no external 
opening. A slight invagination 
indicates the position of the 
future anus, and a similar one, 
the urogenital sinus. 



turbances. According to 
the location of the atresia, we have a hematocolpos, a 
hernatometra, or a hematosalpinx. 

The symptoms are as follows : Pain, at first periodic 



26 



ANOMALIES OF FORMATION. 




Fig. 13.— The Miillerian ducts 
are of larger lumen, and have 
descended with the rectovesical 

septum to empty into the open 
cloaca (P = peritoneum). 



and then continuous, with exacerbations similar to the 

pains of labor ; vesical and rectal disturbances ; indiges- 
tion and vomiting, due to the 
pressure of the accumulated 
blood. Hematosalpinx oc- 
curs in uterine atresias 
earlier than in those of the 
vagina. (Plate 40, Fig. 2.) 
It is dangerous on account 
of the ease with which the 
tubal wall may be torn, 
and consequently the ex- 
amination should be con- 
ducted with great gentle- 
ness. The peritoneum is 

frequently subjected to inflammatory irritation by the 

escape of small quantities of blood from the tubal ostia. 

The same dangers exist in 

collections of blood in closed 

rudimentary cornua. 

In unilateral atresia of a 

double genital canal (uterus 

septus cum vagina septa) 

we have less to fear, as the 

hematoma is more likely to 

rupture into the patulous 

side. (Figs. 10 and 11.) 

The bloody tumor may 

undergo putrefactive or sup- 
purative changes. When 

only one genital canal exists, 

rupture commonly occurs 

through a thinned-out por- 
tion of the cervix. The 




Fig. 14. — The two Miillerian 
ducts have fused to form the 
uterus ( U) ; a septum still exists 
in the fundus. The sinus uro- 
geuitalis is longer (S. u.). G = 
genital eminence = future cli- 
toris ; Pe — perineum. The ure- 
thra opens high up, and is still 
more marked than the genital 
canal. 



blood may escape into the 

peritoneal cavity (peritonitis) or beneath the peritoneum, 
extending down around the vagina to the floor of the 
pelvis — hsematoma vulvae or vaginae. 



ATRESIAS. 



27 




Fig. 15. — External genitalia 
of figures 14 and 16. Behind the 
relatively important genital emi- 
nence (clitoris) the opening of 
the sinus urogenitalis (G) is seen, 
and posterior to this, the aims 
(A). 



In atresia ani vaginalis the feces escape through the 
vagina. (Fig- 3.) If the closure is sphincter-like, a 

periodic discharge of gas 
and feces occurs. When 
the opening is high up in 
the vagina, retention is im- 
possible despite the strictest 
cleanliness. If the opening 
is small or the intestine is 
bent at an acute angle, in- 
flammatory and obstructive 
symptoms may manifest 
themselves. The same is 
true, mutatis mutandis, of 
atresia ani vestibularis (Fig. 
6) and anus perinea lis. 
Complete absence of peri- 
neum may also be observed 
from failure of fusion of 
the lateral eminences. Incontinence of urine exists with 
the more marked degrees of hypospadias, and especially 
with epispadias. (Figs. 4 
and 5.) 

Diagnosis. — Persistent 
nonappearance of the 
menses always demands an 
ocular inspection of the 
parts. AY hen vaginal or 
hymenal atresia exists, the 
bluish prot r udi n g m e m- 
brane is seen, while cervi- 
cal atresia renders the pas- 
sage of the uterine sound 
impossible. Should the 
closure be at the internal os, the cervix alone is patulous ; 
if at the external os, it is impervious. In unilateral 
atresia of duplicate genitalia one side will not permit the 
introduction of a sound. 




Fig. 16. — Further descent of 
the urogenital septum, thereby 
shortening the sinus nroueni talis 



28 



ANOMALIES OF FORMATION. 



Palpation completes the diagnosis. The finger is in- 
troduced into the rectum, and a firm elastic tumor is felt 
anteriorly, above which the uterus is recognized as a small 
hard body. If the distention is more marked, the uterus 
assumes an hour-glass shape, in consequence of the resist- 
ance of the internal os. The tubes should be sought for, 
exercising great care and gentleness. (Figs. 7 to 11.) 

Cord-like atresia of the vagina is recognized by bi- 
manual palpation through the rectum. (Plate 19, Fig. 2.) 




Fig. 17.— During the fifth 
fetal month the cervix (both 
vagina] and supravaginal) is 
differentiated from the vagina 
(Vg.). The urethra is also 
to be distinguished from the 
bladder. The vesicovaginal 
septum assists in the formation 
of the vestibule. 




Fig. 18. — Scheme of the completed 
genitalia after the formation of the 
hymen. 



Treatment. — The gynatretic membrane should be 
incised without delay, and the blood should be shirty 
drained off. Collapse has followed when the latter caution 
has not been observed. If a tubal sac has ruptured, 
immediate celiotomy and removal of the blood are indi- 
cated. Abdominal section is also demanded when the 
hematometra is in a rudimentary accessory cornu. If 
uterus bilocularis or vagina bilocularis (with a septum) 



DUPLICATION. . 29 

exists, it is better to excise the entire partition than simply 
to incise it. 

Cases of pyocolpometra from secondary infection of the 
retained blood are treated in a similar manner, a drainage- 
tube being introduced and the cavity being washed out 
several times daily. 

If there is a complete absence of the vagina (Plate 19, 
Fig. 2), its position being indicated by a fibrous cord, a 
new vagina must be made. Sounds are passed into the 
bladder and rectum, and the operator cautiously dissects 
up through the connective tissue. Skin-grafting should 
be employed to prevent a cicatricial closure of the newly 
formed tube. If adhesions occur in spite of this, or if, 
from the nature of the case, they are to be dreaded from 
the beginning, the ovaries should be removed by abdom- 
inal section and the uterus should be sutured into the vulvar 
wound, in order to prevent a subsequent hydrometra. 

Congenital defects of the perineum and epispadias and 
hypospadias are to be repaired by plastic operations. In 
atresia ani vaginalis the rectum is brought down through 
the perineum as far as possible, and is connected with an 
artificial perineal anus. The fistula then closes either 
spontaneously or after mild cauterizations. 

2 2. HYPERPLASTIC ANOMALIES OF FORMATION. 

i. Duplication of Entire Organs. — 

(a) Of the whole genital tract : 

a. Uterus didelphys : i. e., uterus and vagina grow as the two 
Miilleriau ducts (Figs. 12 and 13), and remain without further 
differentiation as two solid cords or as two tubes ; 
/?. Uterus et vagina duplex : i. e , two genital tubes completely 
differentiated into uteri and vaginae. These lie side by side 
and each possesses a tube and an ovary. 
Both these malformations are seen only in those monsters incapable 
of independent life. At the Munich Frauenklinik I observed two 
examples of type a, with ectopia viscerum, total absence of bladder 
and kidneys, persistent cloaca, etc.; and one of type /?, with eventra- 
tion of all the intestines in an umbilical hernia and with atresia ani. 
Duplication of the vulva is sometimes seen, but has no clinical 
significance. ("Arch. f. Gyn.," 37, 2.) 



30 



ANOMALIES OF FORMATION. 



(b) Of the uterine appendages : ovaries, tubal ostia — 
arising from a division of the Mullerian ducts. 

(c) Of the uterus: bicornis. (Plate 2, Figs. 2 and 19.) 
Those portions of the Mullerian ducts that should form 




the body of the uterus do not fuse, but develop sepa- 
rately, remaining attached to a common neck. This mal- 
formation may be associated with the one to be described 
presently. 



DUPLICATION. 



31 



In the mildest degree of duplication of the uterus the 
fundus simply shows a depression — uterus introrsum arcu- 
atus. 

2. Duplication by a Septum. — The Mullerian ducts 
fuse, but the partition dividing them does not disappear. 




m 




Fig. 20. — Vagina septa with atresia of one canal. Skene's glands 
empty into the urethral orifice (Munich Frauenklinik. "Arch. f. 
Gyn.," 37, 2). 

(Figs. 10, 13, 14.) This disappearance usually begins in 
„ from the eighth to the twelfth week, commencing in that 
' portion of the tube that subsequently (from the twentieth 

to the thirtieth week) forms the vaginal cervix, This 



32 ANOMALIES OF FORMATION, 



PLATE 1. 
The Vulva of a Nonpregnant Multipara (original water color 
from a case at the Heidelberg Frauenklinik). The labia majora and 
minora are separated. In addition to the remains of the hymen, there 
is to be seen a congenital blind canal, about 1 cm. in depth, at the pos- 
terior commissure. The author has repeatedly found analogous struc- 
tures in the fetus (see Plate vn, Fig. 19, of the "Arch. f. Gyn.,' 7 
37, 2), as well as cysts of the hymen in the same situation. The 
perineum is intact. 

PLATE 2. 
Fig. 1.— Intra vaginal Cervix of an "Infantile" Uterus. In 

these and the following analogous illustrations the parts are brought 
into view by Sims' or Simon's specula, the patient being in the dorsal 
position. The labia are held apart, and the furrowed vaginal wall is 
forced back, so that the cervix presents itself in the depth of the 
vaginal funnel. 

The Sims position is the one best adapted for the physician without 
assistance, because then it is necessary to introduce the posterior 
speculum only, the anterior vaginal wall falling back of its own 
accord. The upper half of the body rests upon the left shoulder and 
breast ; the left arm lies upon the table, parallel to the body, and can 
hold the speculum if necessary. The left thigh is almost completely 
extended ; the right is strongly flexed on the abdomen. The physician 
stands behind the patient. 

The illustration represents the pale, small cervix of a deficiently 
developed uterus, often combined with congenital stenosis of the cer- 
vical canal and puerile anteflexion of the uterus. (See £ 3, 1-4, and 
Fig. 22 in text.) 

Fig. 2.— Duplication of Cervix in a Case of Uterus Bicornis 
Septus with a Single Vagina. In the embryo the MLUlerian ducts 
do not lie quite symmetrically side by side, but the right one is nearer 
to the symphysis. This asymmetry may be recognized in the illustra- 
tion, from the relation of the two external orifices to each other. 
(Figs. 10-21 in text and \ 2.) Where the uterus is duplicated, two 
cervices may present themselves in the vagina, which is usually divided 
by a septum. Uterus subseptus may exist with only a single ex- 
ternal OS. 



1 










TREATMENT. 



65 



work for some time. When the genitalia are relaxed and 
the vagina threatens to invert, support the perineum with 
a T-bandage ; on the eighth day of the puerperium a pes- 
sary may be introduced. Catarrh, constipation, and 
tumors are to be appropriately treated. 




Fig. 26. — Incomplete prolapse of the uterus ; inversion of the 
vagina from perineal tear of the third degree (into the rectum). The 
os is notched (photograph from original water-color). 



If the prolapse is beyond the preventive stage, an ap- 
parently rational therapy — from our knowledge of the 
supports of the internal genitalia (based upon the author's 
experiments and those of Kimmel 1 ) — would be the 

1 Kimmel, Inaug. Dis., 1894, Heidelberg. 



66 



VAGINAL AND UTERINE PROLAPSE. 



strengthening of the muscles of the pelvic floor by mass- 
age. This has, nevertheless, been followed by but few 
permanent results. At the present time it is better to treat 
these cases with the pessary or by operation. 

The operative treatment is radical and sure. In retro- 
deviations the uterus is brought forward into its normal 




Fig. 27. — Complete prolapse of a retroflexed uterus, with rectocele. 
The os is notched (photograph from original water-color). 



position by retrofixatio colli uteri, with or without open- 
ing of the recto-uterine pouch ; by shortening the round 
ligaments, either in the inguinal canal or after an anterior 
colpotomy. By the latter route the broad ligaments may 
be shortened or a thickened uterus may be anteflexed by 



TREATMENT. 



67 



excision of a wedge-shaped piece from its anterior wall. 
After the menopause the uterus may be separated from the 
bladder and stitched to the vagina or bladder (vaginofixa- 
tion or vesicofixation of Diihrssen, Mackenrodt). If the 
organ is held by strong adhesions, or if the ligaments and 




Fig. 28. — Complete prolapse of a retroflexed uterus ; simple erosion, 
without rectoeele. (See Fig. 27.) (Photograph from original water- 
color. ) 



vaginal walls are greatly relaxed, ventrofixation should be 
performed ; the best method is that of Czerny-Leopolcl, 
which consists in stitching the uterine serosa (Sanger 
stitches the round or broad ligament) directly to the 
parietal peritoneum of the abdominal wall. 



68 VAGINAL AND UTERINE PROLAPSE. 



PLATE 8. 

Complete Prolapse of an Anteflexed Uterus ; Cystocele. 

Ascertained by the introduction of the sound into the diverticulum 
(note direction of sound ; latter held like a pen). Excoriation of the 
inverted mucous membrane. (Original water-color.) 



Retention is secured by narrowing the vagina and re- 
pairing the perineum ; anterior colporrhaphy of Sims, in 
cystocele, by excising a portion of the mucous membrane 
(shaped like a myrtle leaf) and bringing the edges of the 
wound together ; [An oval denudation (Martin), reaching 
from the meatus urinarius to the cervix, and closed by tier 
sutures of catgut, to narrow the vagina and to leave a firm 
support for the bladder, is the most popular method in 
America for repairing the anterior vaginal wall. Except 
where great elongation of the anterior vaginal wall has 
occurred, the purse-string operation of Stoltz has been dis- 
carded, because it necessarily shortens the anterior vaginal 
wall by approximating the meatus and cervix, and thus 
tends to retrovert the uterus. — Ed.] posterior colporrhaphy 
of G. Simon, Hegar, Bischoff, Martin, v. Winckel, Fritsch, 
Xeugebauer, Kehrer, either by excising a triangular piece 
of mucous membrane, the base corresponding to the peri- 
neum, or by excising pieces of irregular outline and re- 
moving so much of the lateral wall that the posterior wall 
is narrowed and the perineum raised. Posterior colpor- 
rhaphy is also combined with plastic operations on the 
perineum — colpoperineauxesis (Hegar, Kaltenbach) or col- 
poperineoplasty (Bischoff). [The anatomic and physio- 
logic principles embraced by Emmet's colpoperineorrhaphy 
have been so thoroughly appreciated by American sur- 
geons that Emmet's operation is usually chosen to the 
exclusion of all others. — Ed.] These operations should be 
most carefully planned and carried out. The portions to 
be excised are first outlined, then removed, the edges of the 



Tab. 8. 




- / : 



LUh . Anst E Revchhold, Miinchen . 



TREATMENT. 



69 



wound freely loosened up, and the sutures accurately 
placed. 

Considerable experience is necessary to enable the 
operator to remove neither too much nor too little tissue. 
When the operation is completed, the vulva should not 
gape, and the vaginal walls should be well supported by 




Fig. 29. — Complete prolapse of an anteflexed uterus ; simple erosion. 
(See Plate 28.) (Photograph from original water-color.) 



the new perineum. Buried catgut or fine silk may be 
used as suture material in the vagina ; in the perineum, 
silkworm gut or silver wire is to be employed. 

If an ectropion or an ulceration exists, the incision may 
be made to include this portion of the cervix. Not only 



70 VAGINAL AND UTERINE PROLAPSE. 



PLATE 9. 

Extreme Inversion of the Vagina, with Cystocele and 

Incomplete Prolapse of the Retroverted Uterus. (Original 

water-color.) Density of the rnncous membrane. Thickening of the 

vessels. 

superficial parts of the mucous membrane, but also exten- 
sive wedges of muscular tissue (see Metritis), or conic 
pieces of the hypertrophied cervix, may be excised, and 
deep sutures of silk or silkworm gut may then be inserted. 

The preparation of the patient and the after-treatment 
must receive as much care as the operation. Before the 
operation, laxatives, vagina well scrubbed out with anti- 
septics (three times, including the cervical mucosa), and 
the prolapse returned, are measures to be employed because 
the parts are then less vascular. After the operation, three 
weeks in bed ; in the first days, liquid diet and a few drops 
of laudanum ; removal of the perineal stitches at the end of 
the first week ; if nonabsorbable sutures have been used in 
the vagina, they are taken out later. Vaginal irrigation, if 
discharge is fetid ; laxatives, to avoid tension on the sutures. 

If the uterus is so strongly adherent to the hernial sac 
that its reposition is impossible or can not be borne (in 
spite of massage and stretching and tearing the pseudo- 
ligaments), and the subjective disturbances are great, noth- 
ing remains but total extirpation (Kehrer). 

If the operation is refused, pessaries and rings may 
be used for retentive purposes. Among these may be 
mentioned : 

1. The round ring of Mayer (Plate 20, Fig. 3), when 
the lower part of the vagina is still narrow. It is harm- 

PLATE 10. 
Incomplete Prolapse of the Uterus ; Simple Erosion ; " Cir= 
cular" Thickening of Cervix ; Rectocele. (Original water-color 
from a case at the Heidelberg Frauenklinik.) 



H 




PESSARIES. 71 

fill, inasmuch as it dilates the vagina. Those made of 
celluloid or hard rubber are better than the soft-rubber 
variety. 

2. The B. S. Schultze sledge pessary (Figs. 32 and 33) 
corrects the retrodeviation of the uterus and allows a 
natural range of motion when the vagina is very large 
and relaxed. It is better for prolapsus than — 

3. Schultze' s 8-shaped pessary, which is so constructed 
that it is supported by the perineum. (Fig. 31.) It is of 
greatest utility when the introitus vaginae is intact. 

4. Hodge's lever pessary, especially applicable in in- 
version of the anterior vaginal wall (Plate 20, Fig. 4 ; 
Fig. 30), because it does not dilate the middle portion of 
the vagina, but puts it on the stretch. 

5. The Zangerle-Martin stem-pessary (Plate 5, Fig. 3) 
rests upon the levator ani and is applicable in obstinately 
recurring prolapse, and roomy, relaxed genitalia. The 
old stemmed hysterophore is worthless, and is at best to 
be looked upon as a last resort, when the lower vagina is 
dilated. 

The following two pessaries, on the contrary, are not 
sufficiently appreciated in practice : 

6. Hewitt's cradle or clamp pessary (VJ-shaped, a 
ring bent upon itself), and — 

7. Breisky's egg-shaped pessary of hard rubber (espe- 
cially Xos. 2 and 3), which are especially adapted to in- 
operable cases beyond the menopause. It is held in posi- 
tion by a T-bandage, and must be removed with forceps. 

See Directions for the Application of Pessaries, §11. 

The reposition of the prolapsed organ is accomplished 
with the patient in the dorsal position. The pressure 
upon the cervix acts in the direction of the vaginal axis, 
upward and backward, pushing back first the posterior 
vaginal wall, then the uterus, and lastly the anterior vagi- 
nal Avail. Tampons (saturated in glycerin, renewed twice 
daily) retain the prolapse temporarily, the dorsal position 
being maintained. Breisky gave his patients a tampon- 



72 ELEVATIO UTERI. 

PLATE 11. 

Anteflexion of the Uterus in a Child. View of Douglas' 
pouch. (Origiual water-color, from cadaver.) 

carrier, enabling them to introduce the tampons them- 
selves. 

As a supplement to the foregoing, elevatio uteri will 

now be considered. The uterus plays an entirely passive 
role in this change of position, as tumors of the organ 
itself, or of adjacent organs, or peritoneal residues, and 
pseudoligaments lift it wholly or partly above the pelvic 
inlet. (Plate 16, Fig. 1.) 

The diagnosis and the treatment are the same as 
those of the causal affection. The former is often difficult, 
and as the condition is usually associated with structural 
changes, the organ becoming thinner and softer, the sound 
is to be used with caution. The uterus may be joshed 
up from below, or drawn up from above. The cervix 
often projects into the vagina as a mere cone. (Plate 7, 
Fig. 2.) 



eg 



I 



/% 



I 



%»- 



CHAPTER III. 

THE PATHOLOGIC POSITIONS, VERSIONS, AND 
FLEXIONS OF THE UTERUS. 

Pathologic positions are displacements of the uterus 
in toto y the individual portions of the same holding their 
normal mutual relations. They may be forward, back- 
ward, or to one side. Versions are turnings of the uterus, 
as a whole, about an imaginary axis passing through the 
internal os. This axis may have a transverse or a sagit- 
tal direction. In the condition known as a flexion, on 
the contrary, the body of the uterus forms an angle with 
the cervix. These three forms may be observed in com- 
bination with one another or with a " high position." 
(Compare with Elevatio Uteri on p. 72.) Three degrees 
are differentiated, dependent upon whether the fundus 
is above, at the same level with, or below the external 
os. 



gp. THE PATHOLOGIC POSITIONS OF THE UTERUS 
AND ITS ADNEXA. 

The uterus as a whole may be displaced fonvard, back- 
ward, or to one side : antepositio, retropositio, and latero- 
positio (dextropositio and sinistropositio). 

The displacement of the organ is a passive one, the 
most frequent cause being perimetritic or parametritic 
exudates. These may be either recent, tumor-like masses 
forcing the uterus away from them, or contracting bands 
of scar-like adhesions pulling the organ toward them. 
(Plates 44 and 45.) It can thus be seen that the uterus 
may be forced consecutivelv in two opposed directions at 

73 



74 PATHOLOGIC DISPLACEMENT. 



PLATE 12. 
Incomplete Prolapse of the Uterus ; Elongation of the Inter- 
mediate Portion of the Neck with " Circular " Hypertrophy 
of the Vaginal Portion; Inversion of the Anterior Vaginal 
Wall ; Cystocele. The posterior vaginal vault is almost at its normal 
height. (See Plate 4, Fig. 2. ) (Original water-color from a specimen 
in the Munich Frauenklinik.) 

different stages of the disease. (Plate 16, Figs. 1 and 2 ; 
Plate 17, Fig. 1 ; Plate 58, Fig. 2.) 

Tumors act in the same manner. There may be tumors 
of the uterus itself (antepositio from a myoma of the 
posterior wall, Plate 58, 4), tumors of neighboring organs 
(Plate 59, 2 and 4, Ovarian Cystomata), or tumors of 
Douglas' pouch, especially those of the rectum and sa- 
crum. Finally, excessive distention of adjacent organs 
may produce the same result. The bladder (Plate 17, 2, 
and Plate 14, 4), the rectum in cases of chronic constipa- 
tion, and a pyosalpinx (Plate 59, 3) furnish examples. 

A special variety of lateroposition is of a congenital 
and physiologic nature, brought about by unequal growth 
of the Mullerian ducts and their adnexa (tubes, ligamen- 
tum latum). 1 (See Fig. 2 in text.) 

PLATE 13. 
Artificial Prolapse for Operative Purposes, with the Arising 
Inversion of the Vagina and with Cystocele. The uterus first 
assumes a position of retroversion. Further traction directs the organ 
downward in the direction of the vaginal axis (see the dotted lines, 
which show the normal position of the uterus at the beginning and its 
subsequent stages of transition). The pathologic process proceeds in 
the same way. (Original diagrammatic sketch making partial use of a 
drawing of Beigel's.) 

1 In 130 postmortem specimens of adult female genitalia, I found 
the adnexa of the right side longer in 31.5% ; of the left side, in 

27%. 



*M 





Tab. 13. 





in lichen . 



DIAGNOSIS. 75 

Diagnosis. — The presence or absence of a flexion is 
first determined bimanually, and then the cause of the dis- 
placement is ascertained. The changed position of the 
uterus is quite frequently combined with retroversion 
(Plate 17, 2), elevation (Plate 14, 4), or both (Plate 16, 
1). Extra-uterine pregnancy must be excluded if tumors 
of the adnexa or of Douglas' pouch are present. The 
sound is to be employed only after the position of the 
body of the uterus has been accurately determined. It is 
clear from the foregoing that an exact differential diag- 
nosis, especially of the tumors of Douglas' pouch (see p. 
74), must be made. In uncomplicated changes of posi- 
tion both vaginal vaults retain their normal form and 
relations ; the position of the vagina, on the contrary, is 
changed, its curve being lessened and its walls being 
placed under greater tension (anteriorly in antepositio). 

The treatment consists in the removal of tumors and 
the extension of cicatricial bands by massage. 

The tubes and ovaries are frequently displaced by 
inflammatory processes or through relaxation and conges- 
tion of their ligaments. The inflammatory virus (mostly 
gonococci, staphylococci, and streptococci) escapes from the 
abdominal ostium of the tube, and causes perimetritic, 
perisalpingitic, and perioophoritic exudations. Its contrac- 
tion dislocates the movable adnexa, and agglutinates them 
with the intestine and with the serosa of Douglas' pouch. 
(Plates 44 and 45.) The process may cause the tubes to 
be bent at an acute angle. Ovariocolpocele and pyocolpo- 
cele have already been mentioned ; they can, with or with- 
out the uterus, form the contents of almost any variety of 
abdominal hernia. (See § 6 ; § 7, Inversio Uteri Pro- 
lapsi ; Plate 3, Fig. 2.) 

The ovaries usually change their position with the 
uterus, and consequently displacements (one side or both) 
in all directions are encountered. Descent of the ovary, 
combined with retroversion of the uterus, is the most fre- 



76 ANTEVEESION AND ANTEFLEXION. 

quent one (Plate 19, Fig 1) ; the ovary may be palpated 
beneath the uterus. They may also be displaced by tumors 
that proceed from the ovary itself (with or without adhe- 
sion to adjacent viscera) or from neighboring organs. The 
normal position of the internal genitalia is described on 
page 57. 

The symptoms, diagnosis, and treatment will be 
found in the chapter upon inflammation of these parts. 



\ io. THE ANTEVERSIONS AND ANTEFLEXIONS OF THE 
UTERUS. 

Every ante version or anteflexion is not pathologic. By 
pathologic anteflexions are meant only those that are per- 
manent, and that are commonly associated with a lessened 
mobility of the corpus uteri. This lessened mobility may 
refer to its position in the pelvis or to the relation that it 
holds to the cervix. The latter is designated as a " rigid " 
angle of flexion if it has arisen from an inflammatory 
proliferation of connective tissue in an abnormally flexible 
organ. This variety of anteflexion was described in § 3 
(3 and 4) as that of infantile and puerile uteri. 

Etiology. — With the exception of the abnormally 
flexible infantile form, there is always some cause for the 
displacement outside of the uterus. 

1. Cord-like residues of parametritic or perimetritic 
exudates are most common causes. The latter may either 
bind the corpus uteri down to the bladder or to the 
anterior pelvic wall (Plate 14, Fig. 4), or may fix the neck 
posteriorly (this being more frequent). Anteflexion results 
if traction is made upon a still flexible uterus by an adhe- 
sion of the posterior wall corresponding in position to that 
of the internal os. (Plate 15, Fig. 1.) It also follows fixa- 
tion of the neck anteriorly, as shown in plate 15, figure 
2 ; this is a rare occurrence, however. 

2. Tumors likewise produce anteversions and anteflex- 
ions in different ways : either by the pressing downward 



DIAGNOSIS. 77 

and forward of tumors of other organs (ovarian cysto- 
mata), or by a myoma of the anterior uterine wall, which 
can simulate a flexion (determine course of uterine canal 
with sound, see Plate 14, Fig. 3), or by submucous 
polyps, as shown in plate 15, figure 4. Anterior myo- 
mata cause anteversion or anteflexion, according to their 
situation in the cervix or the corpus uteri. 

3. The body of the uterus may likewise tip forward and 
sink down, from an increase of its own weight (metritis, 
hyperemia of menstruation, first weeks of pregnancy). 

4. Ktistner found marked congenital anteflexion of the 
uterus in strong, vigorous children ; my experience confirms 
this, and I have frequently been able to demonstrate, in 
addition, a profuse secretion of glairy mucus in the cervical 
canal and follicular cysts in the ovary. 

Diagnosis. — Certain symptoms and objective signs, 
mentioned in § 3 (3 and 4), are to be emphasized : Dys- 
menorrhea, sterility, constipation, and vesical disturbances 
are not so frequently the result of mechanically changed 
conditions (flexion at the internal os with stenosis, pressure 
of the corpus uteri upon the bladder; Plate 14, Fig. 2 ; 
Plate 15, Fig. 3) as of endometritic and parametritic hy- 
peremia and proliferation. Constipation, associated with 
violent pain and digestive disturbances, and due to the 
cicatricial contraction of pararectal exudates, is one of the 
most constant concomitant phenomena. Catarrh of the 
bladder is also quite frequent. Disturbances of innerva- 
tion play a frequent and important role. 

The pathologic character of the anteversion or ante- 
flexion must be established : the lessened mobility of the 
body of the uterus ; the neck, usually higher and bound 
down posteriorly ; the cause of the fixation, commonly 
parametritic masses of exudation about the cervix (Plate 
59 ; Plate 61, Fig. 2), and its pararectal extensions. The 
sound determines the direction of the cervical canal, and 
the relation that the fundus holds to the long axis of the 
neck is revealed by bimanual palpation. 



78 ANTEVERSION AND ANTEFLEXION. 

PLATE 14. 

Fig. 1.— Anteversion of the Uterus. Normal position, when the 
bladder is empty and the uterus is not bound down. The vagina 
passes in a normal manner from behind forward and from above down- 
ward. 

Fig. 2.— Anteversion of the Uterus (pathologic, as the fundus is 
lower than the cervix). The os looks backward and upward. Cervix 
elevated. Bladder pressed upon. 

Fig. 3.— Myoma of the Anterior Uterine Wall Simulating 
an Anteflexion of the Second or Third Degree. Differential 
diagnosis by the sound. Pressure on the bladder. 

Fig. 4. — Anteversion (or Anteflexion) of a Fixed Uterus (at 
the Same Time Retroposition from a Full Bladder). The corpus 
uteri, bound down to the bladder, is elevated by the rilling of the 
same ; when the angle of flexion is not rigid, extension of the uterine 
axis occurs. 

Treatment. — The cause must be removed as far as 
possible. See sections on parametritis, perimetritis, me- 
tritis, myomata, and § 3 (3 and 4). The symptomatic 
treatment is that of the uterine catarrh (see endometritis), 
the pain (see parametritis and § 4, 8), the vesical disturb- 
ance (see cystitis), and the constipation. The latter must 
be dealt with energetically : tepid injections of water (J— f 
of a liter), oil, or occasionally infusion of senna ; abdom- 
inal massage ; vegetable diet ; and medication by the 
mouth, commencing with the milder drugs. (See thera- 
peutic table.) The intestinal tenesmus is treated with the 
same narcotics as those used for the parametritic pains and 
dysmenorrhea ; these are given in the form of supposi- 
tories or intestinal injections. Hydrotherapy is of value. 
During the inflammatory exacerbations and attacks of pain 
the patient must be kept in bed. 

Contracting scars in the vaginal vault must be excised. 
(Plate 55, Fig. 1.) The treatment with the intra-uterine 
stem-pessary has been portrayed in § 3 (3 and 4). It is 
furthered by the introduction of the round ring of Mayer. 



Tab. 14. 





Fig. 2. 





FipJ. 



Fig. 4^. 



LUh. Anst. F RewMwld, Miinchen. 



TEE ATM EXT. 79 

Cicatricial bands situated high up are to be stretched 
or torn by massage. (Plate 23.) 

§ ii. THE RETROVERSIONS AND RETROFLEXIONS OF 
THE UTERUS. 

When the fundus uteri is placed vertically above the 
neck; or passes backward from it, and the condition is a 
permanent one, we speak of retroversion. We consider 
that its different degrees, as well as those of retroflexion, 
are independent of the absolute height of the fundus. 

Etiology. — Congenital retroversion, or a vertical posi- 
tion of the corpus uteri, is found in feebly developed 
organs. Congenital retroflexions are likewise described 
(Saxtorph, C. Huge, v. Winckel), and puerile retroflexions 
are more frequent than the later pathologic ones. Von 
AVinckel and Kustner explain that some of the latter arise 
from the former by the action of pernicious influences, as 
a habitually full bladder and premature excessive straining'. 
The puerperium may have a similar effect, from the dorsal 
position and the relaxed uterine walls. 

The puerperal process, however, operates in another man- 
ner, furnishing one of the most frequent causes : namely, 
inflammation in combination with injuries of the vaginal 
vault, and stretching, tearing, and relaxation of the geni- 
talia. (Fig. 3 of Plates 16 and 17.) 

Weakened conditions, either general or local (chronic 
diseases, dyscrasias, postpartum subinvolution, neurop- 
athies, masturbation), are also predisposing causes of 
relaxation. In this group belong those cases of simple 
retroversion in which spasmodic flexion has been observed 
by the author. 

The neck may be drawn anteriorly by contracting scars 
(Plate 15, Fig. 2 ; Plate 17, Fig. 4), pushed forward be- 
neath the corpus uteri by tumors (chronic distention of the 
rectum, etc.), or the organ may be bound down to the rec- 
tum or posterior pelvic wall bv perimetritic adhesions. 
(Plate 16, Figs. 1 and 2 ; Plate 38.) 



80 RETROVERSION AXD RETROFLEXIOX. 



PLATE 15. 
Fig. 1. — Anteflexion of the uterus of the second degree 

(fundus uteri at same height as vaginal cervix) from posterior peri- 
metritic adhesions or contracting parametritic exudates of Douglas' 
folds at the level of the internal os. Gaping of external os. Pressure 
on the bladder. The pararectal adhesions produce pain and constipa- 
tion. 

Fig. 2. — Anteflexion of the uterus of the first degree with 
the neck lying horizontally (rare condition) ; the body drawn 
toward the bladder by parametritic adhesions ; a vesical diverticulum 
is drawn toward the internal os. The corpus uteri is vertical. The 
os looks forward and a trifle upward. The vaginal vault is drawn 
anteriorly, so that the vaginal axis is vertical. 

Fig. 3. — Anteflexion of the Infantile Uterus with Stenosis 
of the Cervix and Internal Os ; Dysmenorrhea (more frequent 
condition, see $ 3, 3 and 4). 

Fig. 4. — Anteflexion of the uterus of the third degree (fundus 
lower than the vaginal cervix), caused by a submucous uterine polyp 
(fibromyoma). 

PLATE 16. 

Fig. 1. — Retroversion of a Fixed Uterus. The uterus is verti- 
cal and is fixed by sacro-uterine and recto-uterine adhesions — the 
contracted and shortened uterine ligaments. Vagina put on the 
stretch by the elevation of the uterus. 

In retroversions the chief causes for the deviation are changes in 
the ligaments ; in retroflexion, changes in the uterine parenchyma, 
together with changes in the ligaments. Retroversion easily passes 
into retroflexion. If the adnexa are not bound down in Douglas' 
pouch, they usually lie above the uterus and laterally. 

Fig. 2.— Retroflexion of a fixed uterus (first degree, fundus 
higher than the cervix) ; uterus bound down throughout its entire 
length to serosa of Douglas' pouch by perimetritic adhesions. Cervix 
forced anteriorly, anterior lip thinned, the anterior cervical wall like- 
wise ; posterior lip thickened. Vagina thrown into folds by the 
descensus. Pressure of the intestines upon the uterus. 

Fig. 3.— Slight retroflexion and descent of the puerperal 
uterus from relaxation of the genitalia (dorsal positipri, pressure 



Tab. 15. 





Fiff.l. 



Ffyg. 





Fig.3. 



Fi\ 9 .4, 



LWx. AnstF Retchhold. Miinchen . 



Tab. 16. 





Fig.l. 



Fitf.2. 





Fi ff .3. 



Fig. 4-. 



Lith . Anst F. Reichhold, ilimclien . 



SYMPTOMS. 81 

of the abdominal organs ; later, hard work, etc.). Puerperal metritis 
is very often the cause of subinvolution. 

Fig. 4.— Retroversion of the Uterus (Third Degree, Fundus 
Lower than the Cervix) from Pressure of an Ovarian Cyst. 

The os is directed forward and upward. The vagina is vertical and 
extended. Pressure upon the rectum. 

Uterine myomata (Plate 18, Figs. 1 and 2) or tumors 
of the vesico-uterine space pressing down from above may 
effect retroversion and retroflexion. (Plate 16, Fig. 4.) 
The dorsal position, a heavy, relaxed, puerperal uterus, 
and the weight of the intestines, usually combined with 
descensus uteri (Plate 16, Fig. 3), may bring about pro- 
lapse of a retroflexed uterus. (Plate 4 ; Figs. 27 and 28.) 

Apart from primary inflammatory processes, secondary 
adhesions of the posterior serosa of an already retroverted 
uterus may also occur. 

Symptoms. — Menorrhagia from hyperemia of inflam- 
mation or relaxation, and secondary proliferation of the 
mucosa as a result of the latter ; dysmenorrhea, partly as 
a result of the proliferative changes, partly from the 
mechanical obstruction of the flexion, and spasmodic 
uterine contraction ; catarrhal secretion ; sterility, less 
common than in anteflexion. 

The pressure of the vaginal cervix produces urinary 
disturbances from angulations of the urethra and the ure- 
ters (Plate 19, Fig. 1), and the displacement also inter- 
feres with defecation (flattened, ribbon-like stools). 

Reflex nervous disturbances appear, — not only those 
of digestion (vomiting with migraine, dyspepsia), but also 
those of the respiratory and circulatory organs (tachycar- 
dia, uterine cough, uterine asthma, neuralgia, etc.), — as 
well as a host of hysteric symptoms : convulsions, uncon- 
sciousness, hystero-epilepsy, cardialgia, paraplegia, apho- 
nia, spasmodic cough, globus and clavus hystericus, and 
hypersensitiveness. Motor and sensory disturbances of 
the lower extremities (weakness, formication, cramps of 
6 



82 RETROVERSION AND RETROFLEXION 

PLATE 17. 

Fig. 1. — Encapsulated Peritoneal Exudate in Douglas' Pouch. 
Descent and Anterior Position of a Fixed Uterus (Furrowed, 
Curved Vagina). A circumscribed peritonitis, or a gravitating peri- 
tonitis from other abdominal organs, causes an accumulation of exudate 
in the recto-uterine space ; the overlying intestines roof in the culdesac, 
and by an adhesion of the serous surfaces an encapsulation of the 
pseudotumor is brought about. The uterus is adherent to the blad- 
der as far as the fundus. 

Fig. 2.— -Retroposition of the Uterus by a Full Bladder. From 
its normal attachment to the bladder the uterus is at the same time 
elevated and the vagina extended. The uterine body is directly over 
the vagina, and their longitudinal axes correspond. This position pre- 
disposes to prolapsus uteri ; consequently, the frequent habit of the 
young of imperfectly emptying the bladder may help to bring about 
a descent of the uterus. 

Fig. 3. — Descent and Retroflexion of the Uterus of the First 
Degree, Brought About by Relaxation of the Folds of Doug= 
las. To be recognized by the low position of the vertically situated 
vaginal cervix and by the curvature of the vagina. These symptoms 
make up the picture of relaxation of the genitalia and their support- 
ing apparatus (ligaments and pelvic floor), Avhich predisposes to pro- 
lapse of the genitalia. The external os gapes — ectropion of relaxation. 

Fig. 4. — Retroflexion of the uterus of the first degree, with 
a normally directed neck, caused by the contraction of parametritic 
adhesions that t>ind the latter to the bladder (see \ 11, Etiology). 
The weight of the intestines, combined with relaxation of the uterine 
wall, and the dorsal position (as in puerperium) force the body of the 
uterus backward. 

gastrocnemius) are also observed. They are due to reflex 
action, pressure, or inflammation. 

Diagnosis. — By bimanual examination, after vaginal 
palpation and inspection have shown the anterior cervical 
lip to be thinned and shortened, the posterior lip thick- 
ened, and the os directed toward the symphysis. The 
body of the uterus is palpated either by allowing the ab- 
dominal hand to sink into the pouch of Douglas or from 



Tab. 17. 




Fig.l. 



Fig.2, 





Fig.3. 



Fig.&- 



LiXh. Anst F. Reiditwld, Minchen . 



TREATMENT. 



83 



the rectum. The presence or absence of adhesions must 
be determined. 

Treatment. — The manual treatment of the retrodevia- 
tions is fully demonstrated in plates 21 and 22. By this 
method a freely movable uterus may be replaced : i. e., its 
body laid upon the anterior vaginal vault. Massage may 
be instituted if the organ is bound down by adhesions 
(Thure Brandt, Plate 23), the latter being forcibly torn 
if necessary ; or the contractile elements of the uterus, of 
its ligaments, and of its vessels, may be stimulated. 




Fig. 30. — Hodge's lever pes- 
sary in retroflexion of the uterus, 
first degree. It effects a normal 
position chiefly by causing tension 
of the posterior vaginal vault. 




Fig. 31.— Schultze's 8-shaped 
pessary fixes the cervix in normal 
position ; it is supported by the 
vaginal wall and the pelvic floor. 



If the free uterus can not be replaced by this method, 
the bullet forceps of Kustner is used, or the sound is 
cautiously employed. (See explanation to Figs. 1 and 2, 
Plate 20*) 

When the uterus is brought back into its normal posi- 
tion, a lever-pessary is introduced as a retentive measure. 
(See Figs. 30—33.) Cold douches to the cervix and sacrum, 
alternate hot and cold vaginal douches, ergotin subcutane- 
ously, and tamponade to stpengthen the uterine walls and 
their ligaments are useful adjuvants. 



84 



RETROVERSION AND RETROFLEXION. 



The lever=pessaries are tried in the following order : 

1. The S-shaped Hodge pessary (rather sharply curved), 
when the sacro-uterine ligaments are not sensitive. 

2. The 8-shaped Schultze pessary, when the pelvic floor 
is normal and the vagina is not too relaxed. Sometimes 
the instrument must be quite long. 

3. The sledge-shaped pessary of Schultze, when the 
vagina is relaxed or the pelvic floor is defective. 

4. Hewitt's clamp pessary. (See p. 71.) 




Fig. 32. — Rarer application of 
Schultze's sledge-pessar y with 
firm pelvic floor. 




Fig. 33. — Usual application of 
Schultze's sledge-pessary. It is 
supported by the vaginal wall 
and the symphysis. The cervix 
is fixed between the anterior and 
the posterior bar. Employed in 
retroflexed descended uterus. 



Directions for the Application of Pessaries. — The 

appropriate pessary is to be introduced with the patient in 
the dorsal or knee-elbow position, and the vagina should 
be held open by a duck-bill speculum, allowing the uterus 
and adnexa to fall forward. 

1. The round, flexible caoutchouc ring of Mayer is 
compressed with the fingers or the Fritsch forceps (Plate 
20, Fig. 2), introduced beyond the constrictor vaginae, and 
placed so that the cervix rests within its opening, which 
should not be too small. The ring should slightly dilate 
the vagina. 



PESSARIES. 85 

2. The S-shaped pessary of Hodge and the more curved 
one of Thomas with a bulbous enlargement of the upper 
bar (made of hard rubber or celluloid, rendered flexible 
by hot water, or of copper wire covered with caoutchouc) 
are introduced into the vagina in the sagittal plane. 
(Plate 20, Fig. 4.) When the pessary is above the con- 
strictor vaginae, it is rotated 90 degrees, so that the upper 
and broader bar comes to lie in the posterior vaginal vault, 
as shown in figure 30. 

It acts as follows : The broad posterior bar lifts the 
uterus and pries it anteriorly ; the cervix is drawn poste- 
riorly by the longitudinal and transverse traction upon 
the vagina, and especially upon the uterosacral ligaments. 
From the new position of the cervix and from the pressure 
of the intestines upon the posterior uterine surface the 
uterus rests firmly upon the posterior vaginal wall ; the 
descent of the organ and the accompanying disturbances 
consequently cease, even if the retrodeviation is not 
wholly removed. The tension upon the sacro-uterine 
ligaments resulting from the descent is relieved by the 
transverse tension and elevation of the vaginal vault. In 
married women the simple curved pessary, allowing of 
cohabitation, is the more applicable, the lower bar resting 
upon the pubic symphysis. Should this render the empty- 
ing of the bladder difficult, it may be provided with a 
curve (concave anteriorly). If the upper bar makes the 
vaginal vault too tense, it should be bent backward. 

3. The 8-shaped Schultze pessary is inserted with its 
smaller half about the cervix. (See Fig. 31.) It is made 
of hard rubber or of copper wire covered with caoutchouc, 
and rests upon the pelvic floor. 

4. The sledge-shaped pessary of Schultze is so intro- 
duced that the longer bar lies above and behind the cervix, 
the shorter bar being in front. (Fig. 33.) The shorter 
curvature rests against the pubic symphysis. This pessary 
is used instead of the 8-shaped one when the pelvic floor 
is relaxed. If the vagina is too roomy, the longer bar is 



86 RETROVERSION AND RETROFLEXION. 



PLATE 18. 

Fig. 1.— Retroversion of the Uterus from Two Intramural 
Myomata. By palpation, the condition simulates a retroflexion of 
the second degree. The sound demonstrates the course of the uterine 
canal, and consequently the true condition. External os directed an- 
teriorly. Eectum pressed upon; constipation; Douglas' pouch filled up. 
Urinary disturbances also ensue. 

Fig. 2.— Transition from Retroversion to Retroflexion of 
the Uterus from an Intramural Myoma of the Anterior 
Wall. 

Fig. 3. — Retroflexion of the Uterus of the Third Degree 
(Fundus at the Height of the Cervix). Descent of the uterus 

recognized by the folding of the vaginal wall (the os is below the 
interspinous plane also). Pressure upon the rectum. The os looks 
anteriorly. The uterine body fills the pouch of Douglas. Thick- 
ening of the posterior uterine wall and lip ; thinning of the anterior 
one. 

Fig. 4. — Retroflexion of the Uterus of the Third Degree 
(Fundus Lower than the Cervix). Inveterate case ; os looks ante- 
riorly, gapes widely (ectropion) ; anterior wall of the neck and lip of 
the os thinned. High position of the cervix ; extended, vertical 
vagina. Douglas' pouch filled by the uterine body. 



PLATE 19. 

Fig. 1.— Retroversion of the Uterus; Vaginal Ovariocele. 

Angulation and dilatation of the ureters. Vertical position of the 
vagina. (See \\1 and 11.) 

Fig. 2.— Bimanual Examination from the Rectum of a Case 
of Cord=like Total Atresia of the Vagina with a Rudimentary 
Solid Uterus. During cohabitation the immissio penis has taken 
place into the urethra — probably congenitally funnel-shaped — and 
dilated it as far as the internal sphincter. The palpating finger can be 
pushed into the bladder without difficulty, and its withdrawal is fol- 
lowed by a quantity of urine. A slight incontinence exists. (Original 
diagrammatic drawing from a case.) 



Tab. 18. 





Fig.l. 



Fuj. 2. 





Fiff.J. 



Fig. A . 



Lith. Aast. E Beichhold. Mimchen . 



Tab. 19. 




Fial. 




Lith. Anst F. Reichhold, Miinchen. 



PESSARIES. 87 

brought forward and used as a support, while the smaller 
one holds the cervix in its concavity. Material same as 
preceding : the 8-shaped pessary is made of rings from 8 J 
to 19 cm., the sledge-shaped of rings from 10J to 14 cm., 
in diameter (from 7 to 10 mm. thick). 

A ring is in good position if its lower end is not visible 
at the vulva ; if it does not threaten to fall out ; if it does 
not overdilate the vagina, but may be easily rotated on its 
longitudinal axis ; if the upper half of the vagina is ren- 
dered moderately tense ; finally, if the fundus uteri is an- 
terior and the cervix posterior, since otherwise the folds 
of Douglas are not relaxed. 

If the foregoing conditions are complied with, the dis- 
turbances soon disappear. In only one-fifth of the cases 
is a really permanent cure obtained, so that the uterus 
remains anteriorly without support. 

Disadvantages. — If the ring i> improperly constructed 
(uneven, too large, too thin, or made of wool, hair, leather), 
or remains in position too long, it excites hypersecretion, 
ulcerations, and abscesses. Fistulous tracts communicat- 
ing with neighboring organs may result. Even with a pes- 
sary made of good material, 1 have seen this occur after 
the menopause. If the ulcers cicatrize, embedding the 
ring, or if the latter becomes incrusted with phosphates 
from the secretions or with dried masse- of mucus and 
blood, it is difficult to remove the instrument. After re- 
moval of the wall of granulations the ring is to be seized 
with dressing forceps and extracted by rotatory move- 
ments. It is sometimes necessary first to break it in situ. 

To obviate these difficulties the ring should be removed 
and cleaned after each period, although a pessary may 
remain in. the healthy genitalia for two or three months 
without harmful results. Repeated vaginal irrigations of 
nonirritating fluids must be made : daily, if leukorrhea 
exists. 

The ring is to be immediately removed upon the ap- 
pearance of pain. 



88 RETROVERSION AND RETROFLEXION. 



PLATE 20. 

Fig. 1.— Reposition of a Retroverted Uterus by Means of 
Kustner's Bullet Forceps. The uterus is first brought into the 
vertical position by traction ; the cervix is then pushed backward, and 
the fundus uteri, if freely movable, comes forward. 

Yig 2.— Reposition of a Retroverted Uterus by Means of 
the Sound. The latter is introduced with its concavity directed an- 
teriorly, and is pushed in until its knobbed end has passed the internal 
os. The concavity is now turned posteriorly, corresponding to the 
pathologic course of the uterine axis. If 5 or 6 cm. of the sound have 
passed into the uterus, its knobbed end lies in the fundus. The curva- 
ture of the sound is now cautiously (!) rotated anteriorly, the handle 
of the sound being derjressed at the same time. 

Fig. 3.— Introduction of the Elastic Ring of Mayer by Means 
of Fritsch's Forceps. The ring should lie about the cervix. 

Fig. 4— Introduction of Hodge's Pessary. This is bent into 
the shape of an S. as shown in the adjacent figure (Thomas' pessary 
is still more sharply bent at the upper bar). (See Fig. 30.) 

It is very important to determine whether the displace- 
ment or its complications cause the existing trouble, or 
whether hysteria alone exists. 

The inflammations of the bladder, endometrium, and 
perimetrium are to be treated in the usual manner. If 
adhesions render the reposition impossible, the condition 
is made bearable by firm tamponade of the posterior vag- 
inal vault with glycerin tampons. 

If pregnancy occurs, the pessary is allowed to remain 
until the fifth month ; the retroflexed gravid uterus is to 
be similarly controlled in order to prevent incarceration 
beneath the sacral promontory. 

Operative measures are adopted, partly to dispose of 
very resistant adhesions, which usually elevate the uterus 
considerably, partly to fix the organ anteriorly, either by 
celiotomy or per vaginam. 

If the uterus is freely movable [Alexander's operation. — 



Tab. 20. 





Figl. 



Fig.* 




Fig.J. 




Fig. 4?. 

Lith. Anst.F.ReicMwld, Miiiidien. 



PESSARIES. 89 

Ed.] . retrofixatio colli or vaginofixation is indicated ; if 
it is markedly adherent, ventrofixation (suspensio uteri) is 
to be performed. (See p. 67.) 

The Applicability of Pessaries with Respect to Certain 
Complications of Retroversion. 

1. Retro-uterine Adhesions. — These are to be slowly 
stretched by massage three or four times for at least twelve 
sittings. First elevate in retroposition, to stretch or tear 
the adhesions, then anteflex the uterus, introduce a ring, 
and keep the patient in bed with an ice-bag upon the 
hypogastrium (remember the possible production of a 
hematocele !). The tamponade of the posterior vaginal 
vault is a palliative measure. 

2. Chronic perimetritis furnishes a noli me tangere ; it 
must be cured first (absorption cure). 

3. Parametritic bands and scars from lacerations (Plate 
55, Fig. 1) are excised, the longer diameter of the denu- 
dation being transverse, and the edges are so brought to- 
gether that the row of sutures is in the longitudinal axis of 
the vagina, producing an elongation of the same (Martin). 

4- Chronic Metritis. — This is to be treated first by wedge- 
shaped excisions, and then a pessary is to be applied ; if the 
pessary is not Avell borne, glycerin tampons. In acute me- 
tritis antiphlogistic treatment until the pain has disap- 
peared. 

5. Endometritis. — This will require astringent and anti- 
septic vaginal douches twice daily ; the pessary should be 
frequently removed ; treat the uterus by cauterization, 
intra-uterine irrigation and medication, atmocausis, etc. 
Erosions of the os are to be cauterized or excised. 

6. A stenosis of the cervix is to be dilated or incised. 

7. If the cervix is too short, it exerts insufficient lever- 
age upon the body, which becomes flexed, or the cervix 
slips away from the ring and displacement occurs ; re- 
versed introduction of the Hodge pessary with the upper 
bar posterior is recommended. 



90 RETROVERSION AND RETROFLEXION. 



PLATES 21 AND 22. 
Manual Reposition of a Retroflexed Uterus (First and 
Second Degrees). First step: The body of the uterus is palpated 
from the posterior vaginal vault by the index and middle fingers. 
Second step : While these two fingers push the organ upward, the other 
hand covers in the pelvic inlet, passes behind the uterus, and presses 
down along its posterior surface until (third step) it touches the fingers 
in the vagina. In this manner the uterus is held from above, and is 
hindered from slipping backward. Fourth step : The fingers in the 
vagina may now leave the posterior vaginal vault and push the cervix 
upward, while the external hand presses the fundus toward the apex 
of the bladder, thus forcing the uterus into its normal position. The 
position of the adnexa may be determined by analogous steps. The ab- 
dominal walls should be relaxed (full bath if necessary), and the limbs 
should be flexed at an angle of 60 degrees. The tubes are felt as round 
cords ; the ovaries (which can not be fixed) as bodies of the size of an 
almond. The ovaries lie 2 or 3 cm. laterally and behind the uterus, 
on the inner margins of the psoas muscles. The healthy ovaries 
exhibit a characteristic sensitiveness to pressure. 

8. The anterior vaginal wall being too short, it may he 
lengthened by the operation mentioned under 3 (Skutsch). 

9. The abnormally roomy, relaxed vagina is to be nar- 
rowed by colporrhaphy ; if not permitted reversed applica- 
tion of the sledge-pessary, as in figure 32. 

10. The puerperium is an appropriate time for the treat- 
ment of the organs and ligaments, which at this period are 
capable of being modeled and stretched. Replace by the 
method of Schultze — pushing back the cervix, elevating 

PLATE 23. 
Massage (Thure Brandt). By steps similar to those shown in 
plates 21 and 22 the finger-tips meet behind the retroverted uterus 
and rub and stretch the adhesions between the latter and the rectum. 
At first the blood supply of the adhesions is increased ; they become 
softer and more easily stretched. The uterus is finally "lifted " (Fig. 
2) in order to lengthen the parametritic bands. 



<M 







% 



4 




(>3 




I? 





Tab. 23. 



Fig. 2. 



Lith. Anst E RetcMwld, Mime/ten . 



PESSARIES. 91 

the fundus, and thus causing the body to spring forward. 
Retention is maintained by two glycerin tampons placed 
transversely in the anterior, or, at other times, the poste- 
rior, vaginal vault. Enforced lateral position. 

During pregnancy it is necessary for the ring to remain 
only until the fifth month, because the uterus then holds 
itself in proper position from its increased size. 

11. In narrowing of the introitus vagince (stenosis of the 
hymen, vaginismus) operative measures are to be adopted 
and a ring is to be introduced. 

12. The combination of perineal defect with vaginal 
inversions and prolapsed uterus is to be treated by opera- 
tion ; otherwise, the sledge-pessary. 

13. Tumors and senility are contraindications. 

14. If the ring is in good position and the patient still 
complains, it is to be removed and another cause for the 
disturbances (hysteria) sought. 

Torsion of the uterus is a pathologic turning of the 
uterus about its longitudinal axis, caused by tumors or 
abnormal distention of neighboring organs, or by para- 
metritic or perimetritic fixations. (Plates 44 and 45.) 
It is usually combined with other displacements. The 
vaginal cervix shows the effect of the torsion. (Plate 55.) 

There is a physiologic torsion (cause of the first vertex 
position), since the anterior surface of the uterus, usually 
in dextropositio, is turned toward the right, and the left 
margin approaches the symphysis (the child consequently 
has more room for its back on the left side than on the 
right, which is narrowed by the spinal column). 



GROUP III. 

INFLAMMATORY AND NUTRITIONAL DIS- 
TURBANCES. 



CHAPTER I. 

INFLAMMATION AND ITS CONSEQUENCES: AC= 

QUIRED STENOSES AND ATRESIAS, CONTRAC= 

TIONS OF ORGANS, EXUDATIONS, 

AND ADHESIONS. 

Inflammation in any portion of an organ affects either 
the parenchyma — i. e., the epithelial and glandular tissue 
[glandular inflammation) — or the connective tissue (inter- 
stitial inflammation). Both varieties may occur together. 
The inflammation may run an acute or a chronic course. 
The former variety proceeds with active proliferation 
(hypertrophy and hyperplasia, small round-cell accumula- 
tions); the latter with contraction, due to the transforma- 
tion of the spindle cells into connective-tissue fibers. The 
inflammation causes a more profuse secretion, which may 
be serous, mucous, or purulent, according to its severity 
and the nature of the affected tissue. 

In the majority of cases the inflammation follows upon 
infection with bacteria, among which gonococci, staphylo- 
cocci, and streptococci play by far the most important 
role. 

The nature of the infection will depend upon the inci- 
dents of sexual life (cohabitation, puerperium) ; upon 

92 



ETIOLOGY. 93 

operations, or upon contiguity to diseased organs (tubercu- 
losis). 

Bacteria and yeast fungi found in the secretions of the 
uterine cavity are not always to be considered the cause of 
inflammation. They have entered and flourished either 
because the secretion has become pathologic, or because 
the introitus vaginae and the cervical canal have become 
affected and gape. The primary causes are the frequent 
active and passive hyperemias, resulting from disturbances 
of innervation and atonic conditions of the pelvic and 
abdominal organs. 

The cause of the latter may have originally been infec- 
tious inflammations that have undergone resolution, but 
that have left behind them a diminished contractility of 
all the elastic elements. Such infectious inflammations 
may have occurred in early life. Uterine inflammations 
in virgins are usually of a noninfectious character, and 
the result of masturbation. They lead to a lessened 
tonicity of the whole genital system : hyperemia and 
relaxation of the ligaments, retroversion and retroflexion 
of the descending uterus, swelling and gradual descent of 
the ovaries. In those who have borne children, failure to 
nurse and general weakness play the most important role, 
as well as injudicious conduct during the puerperium, caus- 
ing subinvolution and consequent chronic metritis. In one 
group of such cases the primary cause may have been a 
mild puerperal infection, which has been confined to the 
mucosa. 

Terminations. — Rarely, spontaneous cure ; destruction 
of the parenchyma from retention of secretion, abscess 
formation, or cicatricial contraction ; in some cases the 
general health is affected. 



I 12. GONORRHEA. 

The acute disease arises from infection with the pus of 
a florid urethral gonorrhea : i. e., one rich in gonococci. 



94 GONORRHEA. 



PLATE 24. 

Fig. 1. — Gonorrhea. Papilloma of the hyperemia cervix ; puru- 
lent discharge (from Mracek). 

Fig. 2. — Gonorrheal Cervicitis. Bloody discharge. Erosio 
simplex. (Original water-color.) 

Fig. 3. — Gonococci and Pus=corpuscles. 



(Plate 24, 3.) The vulva and the vestibule are covered 
with thick, yellow, creamy pus, which wells out of the 
vagina upon separation of the labia. As the disease pro- 
gresses the discharge becomes more fluid, but remains 
yellow. (Plates 24 and 27.) The parts are swollen, strik- 
ingly red, and sensitive. If the finger is introduced into 
the vagina and stroking movements are made against the 
pubic symphysis, pus can be stripped from the urethra. 
(Plate 25.) Urination causes marked ardor urinae fol- 
lowed by vesical tenesmus ; every quarter or half hour 
the desire to urinate returns ; the emptying of the bladder 
never seems complete. The symptoms of vesical catarrh 
present themselves ; the urine becomes cloudy and has a 
pungent ammoniacal odor (neutral or even alkaline reac- 
tion). 

Bartholin's glands do not become inflamed until a later 
period (Plates 25 and 26), and in comparatively rare cases 
proliferation of the papillae of the skin occurs (condylomata 
acuminata). (Plate 24, Fig. 1.) 

The vaginal mucosa is likewise inflamed, sensitive, and 
dotted with red points, corresponding to the hyperemia 
papillae. The greater portion of the purulent secretion 
does not come from the vagina (which has no glands), but 
from the cervix, which becomes infected at the same time. 
(Plate 24, 2.) The swollen cervical mucosa is deep red 
and protrudes at the external os ; a cervical endometritis 
consequently exists. At first the process stops at the in- 
ternal os. 




Tab. 24. 



ih. Arist E Reichfwkl, Muncheri . 



CLINICAL COURSE. 95 

Gonorrheal vaginitis, properly speaking, is a more 
chronic process and occurs only in children. 

A different course is taken by infection from a latent 
gonorrhea (gleet of the male, goutte militaire, consisting of 
a very short stricture of the pars membranacea with a 
painless, scanty secretion, especially noticeable as the 
" morning drop " ; rarely, sensitiveness of the urethra and 
epididymis ; during sexual excitement darting pains at 
the root of the penis). A creeping inflammation arises, 
the first symptoms of which (ardor urinse and discharge) 
are usually overlooked. The disturbance becomes more 
marked as the process invades the mucous membrane of 
the body of the uterus. 

In this situation both forms of the disease pursue a 
similar course. 

Endometritis of the body of the uterus causes irregu- 
larities of menstruation, the various pathologic varieties 
alternating (see §4) ; at the same time, as a result of the 
inflammatory hyperemia of the uterus, a sensation of a 
heavy body — of a fullness in the pelvis — presents itself; 
later, there is actual uterine pain. These pains, however, 
may also proceed from inflammations of the tubes, as the 
cocci quickly invade the latter from the uterine cavity. 

Here the process halts for a second time, and the latent 
gonorrhea may remain stationary, just as the acute form 
does at the internal os. The gonococci may, however, 
penetrate into the myometrium, or may gain access to 
the blood and set up new areas of infection, especially in 
the joints. The gonorrhea becomes a lurking chronic 
inflammation with a dubious prognosis. The discharge is 
increased and purulent. 

Frequently the inflammation does not extend to the 
peritoneum from the tube because the isthmus or the fim- 
briated extremity of the latter becomes agglutinated. In 
this way a closed sac is formed, which becomes filled with 
pus — a pyosalpinx. 



96 GONORRHEA. 



PLATE 25. 
Bartholinitis Dextra Gonorrhoeica. Perforation of the abscess 
on the inner surface of the nymphse ; urethritis ; relaxation of the 
vaginal walls. (Original water-color.) 

If the peritoneum is affected, it occurs in one of two 
ways : either through the tissues of the tubal wall by 
means of its lymphatic paths, or by continuity of structure, 
creeping out upon the peritoneum and ovary. The latter 
may likewise be infected by means of the lymphatics or 
from the peritoneum. 

Painful, chronic, circumscribed inflammations of the 
serosa of Douglas' pouch arise — perimetrosalpingitis 
and perimetro-OOphoritis. Interstitial inflammation of 
the ovary may terminate in abscess. These changes are 
accompanied by attacks of fever and considerable pain, 
and lead to serofibrinous exudates in the recto-uterine 
space, which subsequently form adhesions between the 
serous surfaces of the pelvic organs. These are responsi- 
ble for the manifold displacements and anomalies of posi- 
tion of the uterus, its adnexa, the intestinal coils, and the 
rectum. 

The disease of the tubes (it is usually bilateral) is the 
cause of a new symptom — sterility (one-child marriages). 

It is worthy of note that the gonococci prepare the way 
for the pus cocci, so that in the later stages we have to do 
with a mixed infection. 

Symptoms. — Ardor urinse (finally vesical catarrh and 
bartholinitis, the former being recognized by the cloudy, 
alkaline urine containing crystals of triple phosphate and 
acid urate of ammonium, numerous micrococci, and mucus-, 
pus-, and blood-corpuscles ; the latter, by the increased 

PLATE 26. 
Bartholinitis Sinistra Gonorrhoeica. Abscess formation (from 
Mracek). 



Tab. 25. 







I 




Ltth. Anst E Reichhold. Miinchen 



SYMPTOMS. — TEE A TMENT. 9 7 

tenderness, redness, swelling, and finally fluctuation at the 
lower third of the labia rnajora, see Plates 25 and 26) ; 
purulent discharge from the vagina, irregularities of men- 
struation, pain, and sterility. 

Diagnosis. — Demonstration of the gonococci (by stain- 
ing for half a minute in an -effective alcoholic solution of 
methylene-blue — see Plate 24, Fig. 3 ; it is the only coc- 
cus decolorized by Gram's method ; above all, it is found 
within the pus-cells) ; a general or punctiform reddening 
of the vagina ; the pus is seen to come from the cervix ; 
pain is localized in the uterus, adnexa, or peritoneum of 
Douglas' pouch. 

Treatment. — In fresh cases with colpitis alone : Vag- 
inal irrigations with a 5 % solution of protargol (five times 
daily for two weeks, then twice daily with potassium per- 
manganate) ; keep the parts clean, especially the vulva 
(cervicitis is usually present, however). Dilatation of the 
cervical canal by means of metal dilators, after having 
carefully disinfected it and the vagina by means of anti- 
septic solutions ; intra-uterine irrigation with two liters of 
a 0.5^ to % 2.o c /c (even 5^) solution of protargol (increase 
the strength gradually for two or three weeks). Follow- 
ing this, the introduction of h c / c to 10^ protargol salve 
or bougies, wiping out the vagina with a 10^ protargol 
solution and gauze tamponade with protargol salve or pro- 
targol glycerin. In the third week of this treatment the 
application of astringents to remove the remaining swell- 
ing of the mucous membrane mentioned on page 93 : 
Aluminum acetate solution (2 to oft), bismuth subnitrate 
(2 to 3 ft ). This treatment is to be carried out with caution, 
the patient being kept at absolute rest in bed for the greater 
part of its duration, to prevent the disease from spreading 
to the adnexa. It is based upon Neisser's recommenda- 
tion of the silver albuminates (especially protargol) as 
specifics. 

If for any reason this treatment can not be properly 
carried out, we must return to the earlier method of treat- 

7 



98 GONORRHEA. 

PLATE 27. 
Gonorrheal Vulvitis and Vaginitis. Old perineal tear of first 
degree ; external hemorrhoids ; intertrigo. (Original water-color.) 

PLATE 28. 

Fig. 1. — The Microscopic Structure of the Parts of the 
Vulva. (1) Stratified squamous epithelium with the excretory ducts 
(2) of the numerous sebaceous glands of the labium inajus, whose 
connective tissue (3) is sparingly supplied with blood-vessels. (4) 
Stratified squamous epithelium of the nymphae (still without se- 
baceous glands in the fetus), covering numerous connective-tissue 
papillae ; the cavernous tissue is traversed by numerous capillaries, 
which form a mass of erectile tissue at (6). This is surrounded by 
dense bundles of fibers receiving their blood supply from (10) and 
passing to the outer lamella (8) of the hymen, the squamous epithe- 
lium (9) of which is likewise stratified. The inner lamella of the 
hymen is composed of bundles of fibers and vessels, which come from 
the vagina (12). (Original drawing from a specimen obtained from a 
newly born girl.) 

Fig. 2. — Longitudinal Section Through the Cervix in a Case 
of Old Prolapse of the Uterus. The stratified squamous epithelium 
of the cervix shows a superficial horny degeneration. The transition 
from the squamous epithelium of the outer wall of the cervix to the 
cylindric epithelium of the cervical canal is seen at (3). Its displace- 
ment inward is due to the slight ectropion of the lips of the os. The 
stasis of the blood and lymph in prolapsed uteri is apparent from the 
dilated vessels (4). (Original drawing.) (See Plates 10 and 12.) 

Fig. 3. — Simple, Papillary, and Follicular Erosion of the 
Cervix. (Original drawing combined from different specimens.) At 
the left are seen the intact stratified squamous epithelium of the 
vaginal cervix ; this is continuous with cylindric epithelium, which is 
formed by the cuboid cells of the matrix after desquamation of the 
squamous epithelium has occurred (erosio simplex). Further to the 
right are seen papillary elevations with cylindric epithelium (erosio 
papilloides). Glandular follicles showing cystic dilatation from re- 
tained mucus, or filled with exudation, are seen in the inflamed con- 
nective tissue, which is traversed by dilated vessels with round cells 
(erosio follicularis) . Some muscle-fibers are above and to the left. 
(See Plate 29, Fig. 4 ; Plates 33, 35, and 37 ; Plate 60, Fig. 2 ; and 
Plate 90, Fig. 1.) 



j(\ i 


I 


: ic0%W> 


a 


"mm 




'■St-/ 




> ' ^/ 1' •■ 


•^ 


Mr- 


*H 


0' : -\ 





Tab. 28. 




Fig.3. 






Lith. Anst. E Retdtkold, Miinchm. 



TREATMENT. 99 

ment : let the cervix alone, wash away the secretions sev- 
eral times daily with 2 or 3 liters of solutions of silver 
nitrate, potassium permanganate (bright red), bichlorid of 
mercury (1 : 2000 to 1 : 4000), the patient being in the re- 
cumbent posture ; wipe out the vagina several times a week 
and pack with protargol gauze (10 %) ; finally, the patient 
is allowed to introduce tampons of protargol glycerin. 

The husband must have his urethra appropriately 
treated. 

Argonin — also an albumin-silver combination — contains 
less silver than protargol. Argentamin, on account of its 
greater penetration and its ability to excite inflammation, 
is adapted only to neglected cases, in which it is of con- 
siderable service. Nitrate of silver is of value in the 
after-treatment because of its astringent qualities. Largin 
contains 11.1 c /o silver in combination with nucleo-albumin, 
and excels all others in its power of killing the gonococci ; 
it is, however, inferior to them in rendering the soil unfit 
for the organism. 

For the urethritis (female) : wipe out the urethra with a 
5 f protargol solution, sublimate 1 : 5000, or a 2 f solu- 
tion of silver nitrate, and introduce a bf protargol 
bougie every day for a week ; the bladder may eventually 
be washed out with al^ to ^\ c /c protargol solution. 

If the bartholinitis goes on to abscess formation, incise 
when fluctuation occurs and pack with iodoform gauze ; if 
it recurs, excise it entire and bring the edges of the wound 
together. 

Condylomata are removed with scissors or cauterized w T ith 
25 c /c chromic acid, concentrated carbolic acid, or nitric acid. 

Cystitis : Wash out the bladder as previously directed ; 
later, with al^ or 2^ silver nitrate solution and a 2-J^ 
solution of cocain (J to \ liter, lukewarm, using catheter 
and Hegar's funnel, or Kiistner's urethral funnel). 

Internally, diuretic drinks (milk, tea, juniper berries, 
etc.) and urotropin — 0.5 — three times daily. 

In the second group of cases — the older ones — only 
L-ofCt 



100 CHRONIC ENDOMETRITIS. 

PLATE 29. 

Fig. 1. — Elephantiasis Vulvas. (Original drawing.) (1) Strati- 
fied squamous epithelium covering the connective-tissue papillae. Nu- 
merous lymph capillaries (3) are seen in the connective-tissue stroma 
(2). Some round-cell deposits are present, due to the proliferation. 
(See Plate 51, Fig. 1.) 

Fig. 2.— Condyloma Acuminatum. (Original drawing.) (See 
Plate 24, Fig. 1.) Fine dendritic proliferation of the connective-tissue 
papillae (2), which are covered with a very thick layer of stratified 
squamous epithelium (1). 

Fig. 3. — Vaginal Secretion. (1) Polygonal squamous epithelium 
(seen from the side at 6) ; (2) red blood-corpuscles ; (3) leukocytes ; 
(4) oidium albicans ; (5) staphylococci ; (7) bacilli ; (8) trichomonas 
vaginalis. 

Fig. 4.— Cross=section of an Ovule of Naboth Situated in 
the Wall of the External Os. (Original drawing from a speci- 
men.) (1) Simple cylindric epithelium of the cervical mucosa; (2) 
partly desquamated cylindric epithelium from dilated cervical glands 
(ovula Nabothi) ; (3) cervical glands ; (4) stratified squamous epithe- 
lium of the vaginal cervix. (See Plate 37, Fig. 2 ; Plate 60, Fig. 2 ; 
Plate 90, Figs, land 3.) 

after the vagina has been washed out for weeks do we 
proceed to treat the uterus on the principles laid down 
under endometritis and metritis. (See §13.) If affec- 
tions of the adnexa are not rigidly excluded by careful 
bimanual examination, every intra-uterine therapeutic 
measure will be replied to by these organs with an exacer- 
bation of the trouble. The salpingitis, etc., must be first 
treated. (See § 16.) 

In commencing joint affections the temporary constric- 
tion of the extremity is to be carried out according to the 
method of Bier. 

\ 13. CHRONIC ENDOMETRITIS. EROSION AND 
ECTROPION OF THE EXTERNAL OS. 

Endometritis is an affection of the uterine mucous mem- 
brane alone ; it may appear as a disease sui generis without 



Tab. 29. 



M-i '%- \ c 



--Ax^W 




Fig., 











Fig.3. 




Fig. 4-. 
Lith. Anst F. B,eichhold, Miindien . 



CERVICAL ENDOMETRITIS. 101 

affecting other organs, and causes little general disturb- 
ance. 

Although gonorrhea plays the most important role in the 
etiology of the infectious uterine inflammations, there are, 
nevertheless, an important class of cases in which we must 
seek another cause. This is especially true when they 
occur in the virgin. Pyogenic organisms, not infrequently 
owing their introduction to the practice of masturbation, 
are partly responsible for them. 

Another group of cases frequently leading to a general 
disease may be traced to a septic infection, whether it occur 
in the puerperium, or as the result of operative measures 
or of trauma. 

Clinically, we are able to differentiate : 

1 . Catarrh (a) of the cervical mucosa ; (&) of the cor- 
poreal mucosa, usually of a nonbacterial nature. 

2. Purulent inflammation (a) of the cervical mucosa ; 
(6) of the corporeal mucosa, almost without exception of 
a bacterial nature. 

From an anatomic standpoint the first form is synony- 
mous with the pure glandular inflammation ; the second, 
with the interstitial inflammation accompanied by some 
glandular change. (See explanation to Plates 30 and 31 
and p. 107.) 

The affections of the cervix are the more frequent ; those 
of the mucous membrane of the uterus, the more severe. 

(a) Catarrh of the Cervix and Chronic Cervicitis and Their 
Consequences : Erosion and Ectropion. 

The acute inflammation of the mucous membrane and 
wall of the cervix is, without exception, of an infectious 
nature, and is due to the invasion of gonococci or strep- 
tococci following puerperal lacerations, trauma, or oper- 
ations upon the cervix. In the latter case either the 
ulceration of the vaginal cervix or the inflammation of the 
entire uterus and its surrounding connective tissue may 
be the more prominent manifestation. 



102 CHRONIC ENDOMETRITIS. 



PLATE 30. 

Fig. 1.— Normal Uterine Mucosa. (Original diagrammatic 
drawing. ) The mucous membrane of the entire uterus is covered with 
a single layer of ciliated eylindric epithelium. In the cervix these 
cells are club-shaped and considerably higher than in the corpus uteri. 
Both forms produce mucus, which ascends from the more easily stained 
protoplasm about the nucleus to the upper portion of the cell, from 
which it is emptied. As this process goes on, the nucleus of the utric- 
ular cell ascends and descends, while the more actively secreting cer- 
vical cell possesses two constituent parts : a lower rounded portion, 
always containing the nucleus, and devoted to secretion; an upper 
portion, connected with the former by a narrow isthmus, and devoted 
to the storage of the secretion. This upper portion consequently does 
not take the nuclear stains. The nuclei of the cervical cells are neces- 
sarily all at the same level, while in the utricular cells this is not the 
case. The cervical cells are fixed by means of processes that extend 
underneath the contiguous epithelium. In the intact healthy uterus 
the eylindric epithelium extends to the external os, where the squam- 
ous epithelium of the vagina commences. 

The uterus may be anatomically divided into two parts — the body 
and the neck. Corresponding to the utricular and cervical cells, we 
also have two specific forms of glands : large, acinous glands in the cervix 
(cervical glands); long, narrow, tubular glands, chiefly in the body 
(utricular glands). These glands are distributed as follows: 

In the body of the uterus, only tubular utricular glands with low 
epithelium, the nuclei being centrally situated. In the cervix above 
the plicae palmatae, both cervical and utricular glands, the former hav- 
ing unusually high epithelium. In the plicated region, simply folds 
and recesses, no real glands; the plicae are studded with slender, 
thread-like papillae, which are covered by a low, almost cuboid, eylin- 
dric epithelium 

In the lowest portion of the cervix both acinous and tubular glands 
are found; there is also another variety of papillae — low, fungiform, and 
covered with large club-shaped cervical cells. 

The secretion of the healthy uterus is scanty. The vagina contains 
no glands, or only a few (glandula aberr antes) at its junctions with the 
uterus and with the vulva. 

The mucous and submucous connective-tissue stroma is richly sup- 
plied with round cells and vessels, which allow of considerable varia- 




Iig.1. 




Fig.Z. 







FiffJ. 



■M:^+ 



Fig \4r. 

lith. Anst. F. RetcMwUL, Miinchen . 



CERVICAL ENDOMETRITIS. 103 

tion in the degree of swelling of the mncons membrane, whether it be 
momentary or corresponding to the periodic congestions. This also 
explains its rapid regeneration. The muscularis is situated beneath 
the submncosa. 

Fig. 2. — Hyperplastic Glandular Endometritis. (Original 
drawing from a specimen. ) The individual glands are more numerous 
and are increased in extent by lateral pouchings (Ruge) ; the walls are 
enveloped in a connective-tissue capsule, which is richly infiltrated 
with leukocytes and round cells ; the remaining stroma shows practi- 
cally no inflammatory or proliferative process. If the stroma gave 
evidences of the latter, the condition would be known as endometritis 
fungosa (Olshausen), the mucous membrane being considerably thick- 
ened. If the proliferation of glandular and interstitial tissue is cir- 
cumscribed, the condition is known as endometritis polyposa. 

Fig. 3. — Malignant adenoma (glandular cancer) (original 
drawing from a specimen ) differentiates itself from hyperplastic endo- 
metritis by the fact that the glandular ( epithelial ) proliferation exceeds 
that of the connective-tissue stroma ; the relative proportion between 
the two differs from the normal. The glandular tissue eats up the 
stroma, so to speak, destroys the muscularis, and finally invades other 
organs or gives rise to metastases along the lymphatic channels. The 
stroma always shows marked round-cell infiltration; the glandular 
spaces are lined with stratified squamous epithelium — an evidence of 
the active proliferation. There is a striking irregularity in the form 
of the glands and in the picture as a whole. 

Fig. 4. — Hypertrophic Glandular and Interstitial Endome- 
tritis. (Original drawing from a specimen.) The glandular hyper- 
trophic form rarely occurs alone, and consists of an enlargement (no 
increase or marked pouching) of the glands (Ruge); they become 
coiled like a corkscrew, showing, at most, a serrated pouching. In 
this specimen the interglandular tissue shows proliferative round-cell 
infiltration ; hemorrhages have occurred in both glandular and connec- 
tive tissues. The superficial epithelium has undergone partial desqua- 
mation. 

Chronic cervicitis arises as a sequel to such an in- 
flammation, especially if the external os has been lacer- 
ated and gapes. 

The noninfectious inflammations of the cervix present 



104 CHRONIC ENDOMETRITIS. 



PLATE 31. 

Fig. 1. — Acute Interstitial Endometritis. The interglancliilar 
connective tissue is in active proliferation, and consists of densely 
packed round cells. The glands are partly pressed aside and partly 
converted into retention cysts (ovula Nabotlii) by distortion of their 
excretory ducts. Hemorrhage into the stroma. Epithelial desquama- 
tion. (Original drawing from a specimen. ) 

Fig. 2 — Chronic interstitial endometritis is the continuation 
of the former, the round cells becoming changed into rigid connective 
tissue. The glands atrophy. The vessels become thick-walled. The 
superficial epithelium is absent or almost squamous (the squamous epi- 
thelium of the external os can be seen at the left of the illustration). 

Fig. 3.— Postabortive Endometritis. An island of decidual 
cells may be seen under the partly regenerated superficial epithelium. 
Few glands, many round cells, strongly dilated capillary blood-vessels. 



the same clinical picture. A condition of relaxation is 
the primary cause ; it may lead to ectropion even though 
no laceration exists. If the inflammation is limited to 
the mucous membrane, we speak of catarrh of the cervix. 

Symptoms. — The discharge is the first and most con- 
stant symptom. In uncomplicated catarrh it is mucoid ; 
in purulent cases (mixed infection) it is mucopurulent as 
a result of the admixture of pus-corpuscles. This dis- 
charge in time weakens the individual and hinders con- 
ception by the formation of a cervical plug of tough 
mucus. The blood-vessels are overfilled and are easily 
torn on account of the inflammatory proliferation of the 
mucous membrane. (Plate 30.) Reflex menorrhagia 
and dysmenorrhea occur, as well as slight hemorrhages 
from contact. Pain is present, however, in the intervals 
between the periods, if the swollen mucous membrane 
protrudes from the external os — ectropion. (Plate 28, 
Fig. 3 ; Plates 35 and 56.) 

Ectropion usually occurs when the commissures of the 
os uteri have been lacerated. I have repeatedly seen it 



Tab 31. 



J - ) 



- ' ;L 









i> 






J^l. 












u^- 



Wai/8. 



v-I^<-5-t-vSaojv 



" • 



/Ygf.J. 



Zrt/z . Anst F. Rekhhold. Mimchen . 



DIAGNOSIS. 105 

arise in the intact uterus if pessaries were introduced when 
the organ was relaxed and in a lower position than usual. 

Diagnosis. — Palpation discloses the thickening of the 
cervix, and the examining finger is covered with mucus or 
pus. Changes of structure can be felt only in the older 
ectropions, and such a condition should always lead one 
to suspect a beginning cancer. 

Inspection (Speculum). — In a multipara with ectro- 
pion the examination of the mucous membrane is easy ; 
in the closed orifice of the nullipara we discover, at most, 
retention cvsts of the cervical glands — ovula Xabothi. 
(Plate 29, Fig. 4; Plate 56, Fig. 1 ; Plate 69, Figs. 1 
and 3.) In these cases we must draw the os well down 
by means of forceps, evert the lips with tenacula, or dilate 
the external os. 

The cervical cavity is distended by the profuse, tena- 
cious secretion ; this may be demonstrated by the sound. 
(Plates 47 and 67.) 

The secretion also causes a desquamation of the super- 
ficial layers of the squamous epithelium about the os uteri, 
and erosio simplex is produced. (Plate 28, Fig. 3 ; Plate 
33, Fig. 1.) If the cells of the matrix become cylindric 
and arrange themselves in glandular formations, we have 
to do with an erosio papilloides. (Plate 90, Fig. 1.) If 
either one is combined with the formation of ovula Xabothi, 
we speak of erosio follicularis. (Plate 37, Fig. 2.) 

Differential Diagnosis. — Between erosion and ectro- 
pion : In the former the external os is centrally situated 
within the erosion ; in the latter it is outside of, and 
pressed away by, the ectropion. (Plates 33, 37, and 56.) 

Differentiation between erosio papilloides and epithelio- 
matous papilloma is best made bv the microscope. (Plate 
28, Fig. 3 ; Plate 79, Figs. 1 to* 3.) The follicular form 
may produce polypoid excrescences by a circumscribed 
elevation of portions of the mucous membrane. (Plate 
90, Fig 3.) 

Between ectropion (Plates 34, 35, and 56) and incipient 



106 CHRONIC ENDOMETRITIS. 



PLATE 32. 

Fig. 1. — Marked Congestion and Beginning Simple Erosion 
of the Posterior Lip of the Os, as a Sign of Uterine Inflam = 
mation : Endometritis and Metritis. The simple erosion (see 
Plate 33 also ) consists of a casting-off of all the epithelial cells above 
the cuboid layer, allowing the cutaneous capillaries to shine through 
more distinctly. The constant irritation of the uterine secretion is the 
cause of the desquamation. 

Fig. 2. — Slight Congestion of the Cervix of a Multipara 
with a Characteristic, Broad, Fissured External Orifice. 

cancer : Touch is not to be depended upon, since both con- 
ditions offer the sensation of hard, solitary nodules. (Plates 
81, 83, 84, and 90.) Inspection shows ovula Nabothi 
in ectropion ; nodules with destructive ulceration in carci- 
noma. If ulceration does not exist, all that remains is 
the microscopic examination of an excised piece. 

Prognosis. — It is of importance to remember that 
catarrh of the cervix is cured with difficulty, and that the 
inveterate forms have a tendency to malignant degenera- 
tion. 

Treatment. — The local treatment of the cervical mu- 
cosa is exactly the same as that of the uterine mucous mem- 
brane. (See p. 109.) The swelling of the vaginal cervix 
and of the ovules of Naboth is greatly lessened by multi- 
ple punctures and scarifications. If the external os is 
narrow, lateral incisions are to be made — to the vaginal 
vault, if necessary. 

Erosions are to be treated by cauterization : Acetic acid, 
to which 4 fo carbolic acid has been added, is poured into the 

PLATE 33. 

Fig. 1.— Congenital Simple Erosion of the Cervix of a 
Virgin. (Original water-color from a case. ) 

Fig. 2. — Leukorrhea and Simple Erosion. (Original water- 
color from a case. ) 



A 




^■p 




CO 

OS 

H 




SI 



** 




CORPOREAL ENDOMETRITIS. 107 

speculum and allowed to act for several minutes (daily, for 
a few weeks). The reddened ulcerated patches gradually 
disappear as the pathologic cylindric epithelium is replaced 
by epidermoid cells. Weak solutions of cupric sulphate 
or zinc chlorid act more quickly. If the epithelial cov- 
ering is cast off in deeper ulcerations, cauterize with one 
drop of fuming nitric acid, afterward washing out with 
warm water ; otherwise, excise. Above all, remove the 
cause — the discharge. 

Ectropion and follicular hypertrophy of the mucous 
membrane, if present in but a slight degree, vanish when 
the catarrh is treated Avith caustics. The severe forms are 
treated by operative measures : by removal of the swollen 
mucous membrane by means of a wedge-shaped excision 
from the entire thickness of the cervical wall (see Metritis 
under § 14) ; by excision of the connective-tissue commis- 
sures of the gaping os uteri followed by suture. In other 
cases the pessary should be removed and an operation for 
prolapse should be performed. 

(b) Endometritis Corporis Uteri. 

Any endometritis, whether it be cervical or corporeal, 
may appear as an acute or a chronic process, or in milder 
or severer forms. 

The latter division denotes not only difference of grade, 
but also qualitative change : 

The milder forms produce no structural change ; the 
secretion is more profuse and is mucoid and glairy ; hem- 
orrhages occur. 

The severer forms lead to proliferation and to a puru- 
lent discharge. 

There are certain histologic peculiarities that explain 
these differences (see Plates 30 and 31) ; these are as fol- 
lows (Ruge, Veit) : 

I. Endometritis glandularis: (1) Hypertrophic — *. e., the glands 
proliferate in length only, becoming rolled up between the surface of 
the mucosa and the muscularis. Their longitudinal section resembles 



108 CHRONIC ENDOMETRITIS. 



PLATE 34. 

Ectropion with Extreme Relaxation of the Cervical Wall 
and Intact Commissures of the External Os. Anemic cervix fol- 
lowing climacteric menorrhagias from myomata. (Original water- 
color from actual case. ) 



a corkscrew. (2) Hyperplastic — the glands proliferate in length and 
breadth, forming lateral pockets. 

II. Endometritis interstitialis : (1) Acnte ronnd-cell proliferation 
leads to purulent secretion ; ( 2 ) chronic or cirrhotic connective-tissue 
formation, contraction, leading at last to atrophic endometritis. 

The glandular forms occur as mixed forms, especially with acute 
interstitial endometritis ; if the hyperplasia and proliferation are pro- 
nounced, we have: 

III. Endometritis fungosa (mixed form), if the proliferation is 
diffuse ; or — 

TV. Endometritis polyposa (mixed form) and endometritis follicu- 
laris (Plate 90, 3), if it is circumscribed. 

From groups II and III the following varieties may be separated, 
their most striking symptom being either hemorrhage or a casting-off 
of the mucosa : 

Y . Endometritis exfoliativa ( dysmenorrhea membranacea, see \ 3 ) . 
VI. Endometritis dissecans with phlegmon. 

VII. Endometritis hemorrhagica ; scanty secretion; fungous mu- 
cosa ; after abortion in acute infectious diseases. 

If the endometritis is the result of an abortion, we designate it as : 
VIII. Endometritis post abortum, to be recognized by the large 
decidual cells. 

The ovules of Xaboth arise (Plate 29, Fig. 4 ; 56, Fig. 1 ; 69, Figs, 
land 3): 

1. From excessive proliferation and secretion in I (2). 

2. From a too narrow excretory duct in I (1). 

3. From occlusion of duct by angulation in I (1). 

4. From compression of duct by inflamed connective tissue in II (1). 

5. From cicatricial closure in II (2). 

The symptoms of chronic endometritis corporis uteri 
are the same in infectious and noninfectious cases : 

1. Pain, at the time of the menses (dysmenorrhea), 

PLATE 35. 
Mucous Polyp and Ectropion of the Anterior Lip of the 
Uterus. The cervical walls are relaxed and anemic ; the commis- 
sure of the os uteri is intact. (Original water-color from actual case.) 



Tab. 34 




LUfCAnst F RsLchhvld, Munthai. 



Tab. 35. 




Liih . Anst K Reichtwld, Muncheii . 



DIA GNOSIS.— TEE A TMENT. 109 

with or without casting-off a decidua menstrualis ; or, 
rarely, in the interval (intermenstrual pain) ; or permanent, 
ceasing with the beginning of the flow, so that the men- 
strual period is the only time at which there is no pain ; 
or permanent, with exacerbations at the menstrual epoch. 
(See § 17.) 

2. Discharge, mostly bloody, serous, mucoid (Kiistner, 
Schroder) and purulent (B. S. Schultze). Determined by 
means of tampons. 

3. Changed character of menstruation ; menorrhagia 
and dysmenorrhea. 

4. Sterility. 

5. Reflex nervous disturbances : pains in the umbilical 
region, dyspepsia, all varieties of hysteric troubles. 

As the myometrium is usually involved, the symptoms 
of myometritis may complicate the clinical picture. 

Diagnosis. — 1. The sound causes characteristic pain as 
it passes the internal os ; the entire uterine mucosa is hyper- 
sensitive. The sound also reveals the size of the uterine 
cavity and any roughenings or fungosities that may be 
present. 

2. Abrasio mucosae (curetment, raclage, excochleation) 
— the tissue is removed and its structure examined with 
the microscope. 

3. In doubtful cases the cervical canal is dilated (metal 
dilator of Fritsch, Kustner's adjustable dilator, lamin- 
aria — well sterilized) and the entire uterine cavity is 
palpated. 

Prognosis. — Serious results follow from the hemor- 
rhage and from the discharge, as well as from the occur- 
rence of malignant degeneration. 

Treatment. — Above all, provide for a regular and 
sufficient discharge of the secretions. The external os, 
and especially the internal os (normally 4 mm. in diam- 
eter), are usually constricted frtfm the inflammatory swell- 
ing of the mucosa, and may require mechanical dilatation. 
To aid in removing the secretions, vaginal irrigations 



110 CHRONIC EXDOJIETBITIS. 



PLATE 36. 

Figs. 1 a, 1 &, 1 e. — Different Molds of the Uterocervical 
Canal as Shown by Swollen Laminaria. The end to which the 
silk thread is attached lay in the external os. (Original water-color 
from actual cases. ) 

Fig. 2. — Curetment in Fungous Endometritis. Relaxed, 
anemic cervix ; sharp, although irregular limitation of the squamous 
epithelium at the external os. (Original water-color from actual 
case. ) 

with astringents (alum, tannin, bismuth subnitrate, zinc 
sulphate) or antiseptics (potassium permanganate, solu- 
tion of aluminum acetate, 1 formalin, 1 : 4000 to 1 : 2000 
corrosive sublimate), exciting the uterus to contraction 
and washing the cervical mucosa. 

The character of the diseased mucous membrane must 
be changed by using astringents or caustics. The stronger 
caustics (10 ^ zinc chlorid, for example) should not be 
used, as they may produce strictures, stenoses, and patho- 
logic adhesions. These substances are best applied in 
liquid form (sesquichlorid of iron in 50^ solution or 
pure, 2 c / c solution of silver nitrate, 5 c / solution of zinc 
chlorid, fuming nitric acid) by means of cotton and the 
aluminum sound. 

At the same time the infectious virus must be removed, 
either by the foregoing caustics or by antiseptics. In 
addition to intra-uterine irrigation (Fritsch's two-way 
catheter), pencils of itrol or iodoform may be introduced. 

The cervix may be dilated and the uterine cavity may 
be disinfected at the same time by packing the uterus with 
itrol or iodoform gauze (following Abel, to be removed 
daily). Landau introduces yeast cultures. 

The changed and infected mucous membrane may be 
removed by radical methods — abrasion, curetment (rac- 
lage, excochleation). 

1 See Therapeutic Table. 







/ 



TREATMENT. Ill 

After careful disinfection and dilatation the cervix is 
fixed with bullet-forceps and the uterine walls are care- 
fully and evenly scraped. Simon's sharp spoon or the 
dull wire curet may be used. [The dull wire curet is 
practically useless. — Ed.] The various portions of the 
cavity should be cureted in some definite order. The 
cureting is to be immediately followed by packing with 
antiseptic gauze (itrol, iodoform) or with gauze saturated 
with some caustic (solution of ferric chlorid, formalin). 
This controls the hemorrhage, acts as a disinfectant, and 
brings the medicament in contact with the remaining 
diseased mucous membrane. It is still better to follow 
up the curetment with atmocausis or zestocausis. (See 
Treatment of Chronic Metritis.) 

Narcosis is necessary in the majority of cases. The 
intra-uterine irrigations may sometimes cause colic. 

For three or four days after the curetment daily intra- 
uterine douches of 2 c / c carbolic acid act favorably ; in the 
marked cases of proliferative fungous endometritis the pro- 
cess is kept within bounds by washing out the uterine 
cavity twice daily, and then applying astringents (solution 
of sesquichlorid of iron, tincture of iodin) by means of 
the sound. 

According to my experience, atmocausis and zestocausis 
(vaporization, vapocauterization) are productive of better 
and more permanent results than these scraping and cau- 
terizing methods. 



I 14. CHRONIC METRITIS. 

The clinical picture of chronic metritis consists of inflam- 
matory hyperemia and swelling and sensitiveness of the 
entire organ. It leads to a connective-tissue hyperplasia 
rather than to a proliferation of the muscle-cells. The 
inflammation progresses slowly, with acute and subacute 
exacerbations, and in some cases ends in cirrhosis. The 
endometrium is nearly always diseased, and consequently 



112 CHRONIC METRITIS. 



PLATE 37. 

Fig. 1. — Chronic Metritis with Ovula Nabothi. Metritis is 
an inflaniniation of the uterine muscular is. If the process is of long 
duration, the muscle-cells are partly replaced by scar-tissue (see Plate 
31, Fig. 2), which in our illustration retracts the cervical mucosa and 
causes a visible wrinkling. The ovula Nabothi are retention cysts, 
resulting from distortion of the ducts by contracting connective tissue. 
(Plate 29, Fig. 4.) 

Fig. 2. — Gonorrheal Endometritis with Simple Erosion and 
Ovules of Naboth; Inflammatory Hyperemia. (Plates 29, 30, 
and 31. ) Thick, yellow, creamy pus flows from the os and fills the 
vagina. The ovula Nabothi are also filled with pus. The erosion is 
the result of the endometritis. The simple infection with gonococci 
soon gives place to a mixed infection with staphylococci and strep- 
tococci, the former organisms having prepared the soil for the latter. 
The process creeps up the tubes and then progresses to the nearest peri- 
toneal surface (metritis, oophoritis, perisalpingitis), at first producing 
exudations, then adhesions and cicatricial bands. (Plates 44 and 45, 
Fig. 36. ) The gonococci, as a rule, invade only the supe icial layers 
of those membranes covered with cylindric epithelium. 

The adhesions of the tubes and ovaries lead to the fori. »n of ab- 
scesses ( Pyosalpinx, Plate 42 ) and sterility. The perimetritic process 
causes displacements of the uterus and its adiiexa. 

the symptoms of myometritis and endometritis are insepa- 
rably associated. 

There are two stages : ( a ) The stage of hyperemia and round-cell 
infiltration : the uterus is soft and easily torn, as a result of the edema 
and fatty degeneration of the muscularis. (b) The stage of cirrhotic 
induration : the uterus is tough, anemic, or livid from venous stasis 

PLATE 38. 
Retroversion of the Fixed Uterus (First Degree) and Ag= 
glutination of the Cervix (Acquired). A peritoneal pseudoliga- 
ment holds the uterine fundus in retroversion. Caustics or senile 
processes cause adhesions and, later, atresia of the cervix. Changed 
direction of the vagina in retroversion of the uterus. (Original water- 
color from a specimen in the Munich Frauenklinik. ) 



ETIOLOG Y. —DIA GNOSIS. 113 

(arterial walls thickened, their lumen narrowed, muscularis partly 
replaced by connective tissue). 

Etiology. — (1) From puerperal subinvolution; (2) 
from the irritation of a chronic endometritis \ (3) from 
the penetration of infectious germs (especially gonococci) ; 
(4) from other hyperemic irritations, such as masturba- 
tion ; (5) from venous stasis in flexions, prolapse, or other 
displacements accompanied by engorgements . (habitually 
full bladder, chronic constipation, or secondary stasis from 
circulatory disturbances in other organs) ; (6) rarely, from 
an acute metritis. 

Prognosis. — Although the disease does not cease at the 
menopause, but usually several years later, this time is the 
best for effective treatment. The prognosis is more favor- 
able if the second stage appears early, as the disturbances 
then disappear. 

Symptoms. — A sensation of fullness (as if a heavy 
body were in the abdomen), pains in the side and sacral 
region, discharge, menorrhagia, dysmenorrhea, dysuria, 
and constipation. The symptoms are more pronounced 
at the menstrual epoch or when obstinate constipation 
exists. They are favorably influenced by rest in the dor- 
sal position. 

Diagnosis. — The cervix is soft, thickened, and hyper- 
emic, with swollen lips, from the accompanying endo- 
metritis — ectropion, erosion, ovula Nabothi. (Plates 32 
and 56.) In the second stage the cervix is livid, hard, 
and wrinkled. (Plate 37, Fig. 1.) 

Hypersensitiveness is not always present, but a peculiar 
softening and enlargement of the organ occur, causing 
it to resemble a gravid uterus at the second and third 
months. The sound reveals the elongation of the uterine 
cavity and a thickening of its wall. 

Any variety of inflammation of the surrounding tissues 
and organs may occur. Conception takes place with diffi- 
culty, and leads to abortion or to premature delivery. 

Differential Diagnosis. — In the first months it is dif- 



114 CHRONIC METRITIS. 



PLATE 39. 
Acute Purulent Pelvic Peritonitis (Peritonitis of Perfora= 
tion). View of pouch of Douglas and the posterior wall of the uterus 
and left broad ligament with its tube and ovary. The pus has been 
wiped off of the uterus but allowed to remain on the serosa of Doug- 
las' pouch. (Original water-color from a specimen at the Heidelberg 
Pathologic Institute. ) 

ficult to differentiate a gravid uterus from an inflamed 
organ ; the former is softer, especially at the cervix and 
internal os (bimanual from the rectum), and rests upon 
the cervix like a round, thickened body ; the latter is more 
sensitive. Pregnancy must always be thought of, espe- 
cially if intra-uterine treatment is under consideration. 

Intra-uterine tumors may be palpated with the sound, 
or directly with the finger after dilatation of the cervix. 
The inflamed uterus is elongated, especially the cervix, 
which is contracted in virgins and everted in multipara. 
In cancer small pieces may be removed and examined 
microscopically. 

If the case is simply one of endometritis, the increase 
in volume and the hypersensitiveness of the entire organ 
are not marked. 

Treatment. — Prophylactic. — During menstruation : 
rest in bed (not all the time) ; avoid everything inducing 
congestion (excitement, especially sexual ; heating drinks ; 
constipation ; colds). During the puerperium : Ergotin, 
warm or cold applications, abdominal massage ; hot vag- 
inal irrigations (117° to 127° F.) or warm general baths 
(95° to 100° F.) in the second w^eek. 

Special treatment of the hyperemic stage — absorptive : 
hot injections and baths, with or without salt or lye. 

The hyperemia is controlled by constricting the vessels : 
Ergot or ergotin, hyclrastis, stypticin ; hot vaginal injec- 
tions ; scarifications of the cervix (every three or four 
days, J to 2 fluidrams, especially before the period) relieve 



Tab. 39. 




lith.An.st F. ReicMiold.Uihuhai. 



TREATMENT. 115 

congestion and pain. Compression by means of vaginal 
tamponade and sand-bags or shot-bags laid upon the ab- 
domen. 

Glycerin tampons are used as derivatives, and the secre- 
tion is further stimulated by astringents and caustics. 
The applications are to be repeated every week, but only 
in the first stage. Curetment, followed by chlorid of iron 
or iodin (Playfair's aluminum sound). 

The application of steam to control hemorrhage (nienor- 
rhagia) is, according to the author's experience with atmo- 
causis, a most valuable addition to our therapeutic measures. 
It was first employed by Snegirew, the instrumentarium 
being perfected by Pinkus. My own observations show 
that it is as effective in obstinate endometritis as it is in 
inflammations of the myometrium. It is not advisable 
for one unskilled in gynecologic practice to make use of 
this method, especially if he is without assistance. It is 
as little adapted for ambulatory treatment as is curet- 
ment. 

The instrumentarium is as follows : A tested boiler with 
safety-valve and thermometer ; a rubber tube (tightly 
screwed to the boiler), rather thick and well wrapped ; and 
a two-way intra-uterine catheter with a discharge-tube for 
the steam returning from the uterine cavity. The catheter 
is covered with gauze or celluloid to protect the cervix 
from injury and subsequent stenosis. The pressure and 
temperature of the steam and the duration of its action 
must be gaged to suit the individual case. A cureted 
uterus or one having a small cavity must be treated more 
mildly, probably using only the zestocautery : i. e., the 
closed catheter, 105° to 112° C, for from ten to twenty 
seconds ; with a large cavity and a thickened endometrium, 
110° to 115° C, for fifteen seconds. If obliteration is 
desired, steam at 1 15° to 120° C. for from one-half to two 
minutes is to be employed. This may be repeated, whereas 
ordinarily the application should not be renewed until the 
next menstrual period has passed. Narcosis is not neces- 






116 CHRONIC 3IETBITIS. 

sary, but is usually desirable ; the same is true of assistance. 
The cervix must be dilated. 

The methods of treatment just named are symptomatic 
and palliative. If pain and a sensation of fullness are 
present : frequent scarifications and glycerin tampons ; 
abdominal belt and pessary to remove tension from the 
uterine ligaments. 

For the menstrual disturbances : Previous scarifications, 
warm sand-bags upon the abdomen or warm alcoholic 
fomentations (narcotics). In menorrhagia : ergotin, tam- 
ponade, application of ferripyrin or introduction of ferri- 
pyrin-gauze tampons, gelatin injections, atmocausis. 

Operations for the Purpose of Reducing the Size of the Collum 
Uteri and Removing the Diseased Mucous Membrane. 

These results, together with the removal of scars from 
lacerations, are best accomplished by means of wedge- 
shaped excisions (or amputation of the cervix, removal of 
conic pieces of tissue — operations of Sims, Hegar, Simon, 
Schroder). The following operations are to be particu- 
larly recommended : 

Schroder's Operation. — The inner circumference of the 
os with its diseased mucous membrane is completely 
excised. The remaining outer half of the cervical wall is 
turned in and sewed to the remains of the cervical mucosa. 

A. Martin's Operation. — The entire vaginal cervix is 
excised in the shape of a cone. The cervical mucosa is 
then drawn down and stitched to that of the vagina. 

Kehrer's Operation. — AYedge-shaped pieces are excised 
from both lips of the os uteri. Their base is formed by 
the cervical mucosa, and they extend through the entire 
cervical wall. 

After the Operation. — Glycerin or iodoform-gauze tam- 
ponade (one day) ; then vaginal irrigations ; for secondary 
hemorrhage firm gauze tamponade with ferripyrin, solution 
of sesquichlorid of iron, or suture ; if catgut has not been 
employed, removal of sutures in eight days. 



VUL VITIS.— COLPITIS. 117 



I 15. SEPSIS. 

(Acute Vulvitis, Vaginitis, Endometritis, Myometritis, Sal= 
pingitis, Parametritis and Perimetritis, Peritonitis.) 

The acute inflammations of the endometrium and myo- 
metrium present practically the same clinical pictures. 
They are due to the invasion either of gonococci or of 
septic germs. It is to the inflammations caused by the 
latter that attention is now directed. 

Etiology and Clinical Aspect. — Invading pyogenic 
organisms (streptococcus pyogenes ; staphylococcus aureus, 
albus, citreus, etc.) excite septic inflammations ; the ave- 
nues of infection are either the skin or mucous membrane 
of the genitalia, or the peritoneal covering. 

The opportunity for invasion through the lining mucous 
membrane is given by trauma, by faulty technic in opera- 
tions and examinations (sounds, dilators), or by the puer- 
peral process. 

By virtue of the peculiar quality of the secretion and 
of the wound surface, which is particularly adapted for 
the multiplication of invading organisms, the puerperal 
infections are of the greatest importance. The secretions 
may stagnate in closed spaces, at body-temperature, and in 
direct communication with numerous lymphatic channels. 

The " gynecologic " infections take the following courses, 
according to their point of introduction, the infection de- 
pending not only upon the place of entrance, but also upon 
the virulence of the germ and upon the general and local 
power of resistance of the individual. 

Vulva (Phlegmone Vulvce). — The infection usually re- 
mains local and leads to abscess formation. The perineal 
infections, especially when near the rectum, lead to throm- 
bophlebitis and general infection. 

Vagina {Colpitis Crouposa et Diphtheritica, Phlegmone 
Vagince, Abscesses, Paracolpitis, Paraproctitis), — The in- 
fection remains local, at most spreading to the adjoining 



118 SEPSIS. 



PLATE 40. 

Fig. 1. — Acute Catarrhal Parenchymatous Salpingitis (Due 
to Gonococci and Streptococci). The tubal catarrh is the first 
consequence of the invasion of the cocci in the endosalpinx, and it 
produces a hypersecretion of mucus. The endosalpinx commences to 
proliferate ; the connective-tissue papillae ( 1 ) , covered with columnar 
ciliated epithelium, form dendritic ramifications that fill the lumen 
of the tube (2). The stroma of the papilla is infiltrated with young 
round cells ( 6 ) . The submucosa ( 4 ) and the muscularis ( 5 ) are still 
healthy, but there is a commencing perivascular (3) round-cell infil- 
tration. (Original drawing from a specimen. ) 

Fig. 2. — Hematosalpinx. In gynatresias (see Figs. 7-11 in text) 
the menstrual blood remains in the uterus and finally dilates the tube 
(2); the epithelium (1) desquamates after the papillae (3) have been 
flattened by pressure ; the vessels ( 5 ) of the submucosa ( 4 ) are dilated 
from stasis ; there is a reactionary round-cell accumulation (7) about 
the blood-vessels in the muscularis (6). Tubal hemorrhages occur 
during the periods, in heart disease and kidney disease, in cases of 
myomata and ovarian cystomata, and in extra-uterine pregnancy. 
(Original drawing from a specimen.) 

Fig. 3.— Pyosalpinx. The ostia being closed, the pus distends 
the tube. The epithelium (1) is completely destroyed ; the papillae (2) 
are flattened ; the stroma (3), rich in round cells, is bathed in pus; 
and the elasticity of the tubal wall is destroyed because the muscle- 
fibers (4) are separated and replaced by connective tissue (6). The 
submucous capillaries are dilated from stasis; the vessels of the mus- 
cular layer show a chronic inflammatory thickening. Such pus sacs 
contain different varieties of microbes, the virulence of which depends 
upon the age of the abscess at the time of its rupture. (Original draw- 
ing from a specimen.) 

connective tissue. Contrary to what is the rule in puer- 
peral cases, the process very rarely extends to the uterus. 

Uterus (Endometritis et Metritis Acuta). — The course is 
doubtful, and if progressive, it may be a very chronic 
afYection. 

Symptoms. — Bloody and mucopurulent discharge; 
enlargement and hypersensitiveness of the uterus (expe- 



o 

as 


















.OS 



■3 




SYMPTOMS. 119 

rienced by the patient as a dull pain in the pelvis, in- 
creased by movement, coughing, straining, etc.) ; stran- 
gury ; diarrhea with violent tenesmus ; fever (rarely, ab- 
scess formation). 

The patients soon show evidences of a severe infec- 
tion. They are pale and hollow-eyed ; no appetite ; 
meteorismus — pulse-rate and temperature increase ; the 
abdomen becomes sensitive. These are all symptoms of 
beginning parametritis and perimetritis. 

Vaginal examination (to be most gently carried out) 
reveals hypersensitiveness of the vaginal vault and re- 
sistance behind the uterus. Rectal examination shows a 
tumor behind or beside the uterus, the differentiation of 
the two being impossible by palpation. Anatomically, it 
may be a pyosalpinx, oophoritis, perimetrosalpingitis, peri- 
oophoritis, or parametritis. 

The process may remain stationary at this point. The 
intestinal coils, which roof in the pouch of Douglas, be- 
come adherent and wall off the exudate from the general 
peritoneal cavity — peritonitis exsudativa saccata. The 
inflammatory products may undergo absorption, may per- 
forate into the rectum, or, rarely, may perforate into the 
vagina. Chills are present. Permanent resistance beside 
the uterus may be demonstrated. 

As sequels may be mentioned dysmenorrhea, sterility, 
and deviations of the uterus, the intra-uterine treatment 
of which, as well as the periodic congestions, may produce 
febrile exacerbations. 

If the inflammation proceeds, a general peritonitis 
occurs with marked meteorismus, great abdominal pain 
(which may be absent or intense only at times), compres- 
sion of the rectum, hindered passage of flatus, threatening 
symptoms of obstruction, vomiting (even fecal), and some- 
times profuse fetid diarrheas. The pulse is rapid, small, 
and irregular. 

The patient may die, the fever being no more pro- 
nounced than the anatomic changes. The patient may 



120 SEPSIS. 

recover slowly, the pus being absorbed ; or rapidly, the 
pus emptying externally or into some hollow viscus. 

Diagnosis. — Ulcers of the vulva, vagina, and cervix 
are seen most frequently in the puerperium, occurring 
elsewhere only in children and in severe acute infectious 
diseases, such as croupous diphtheria and gangrenous 
vulvitis. The diagnosis is made by the fetid discharge, 
pain, slight elevation of temperature, and the gray, green, 
or yellowish covering of the. wound. Ulcers situated near 
the perineum may be due to injuries or ulcerative pro- 
cesses of the rectum ; or to inflammations of the glands of 
Bartholin, which in rare cases are not of a gonorrheal 
nature. 

Acute colpitis and endometritis, with their concomi- 
tants, myocolpitis and myometritis, may be brought about 
not only by gonorrhea and puerperal infection, but also 
by a cold followed by menstrual suppression, by septic 
operative measures, or by acute infectious diseases (influ- 
enza and others). 

The main symptoms are fever, purulent secretion, hem- 
orrhages, and pain in the interior of the uterus. The 
cervix is swollen, and the external os is ulcerated, eroded, 
and covered with purulent ovula Nabothi. (Plate 37, 
Fig. 2.) 

The deeper the process penetrates into the perivascular 
and interstitial connective tissue of the muscularis, the 
more violent will be the febrile invasion. This is accom- 
panied by chills, by hypersensitiveness of the enlarged, 
hyperemic, softened uterus, by dull pelvic pain, and by 
vesical and rectal pain and tenesmus. If abscesses form 
later, their presence is detected by fluctuation. 

Parametritis seems, to the touch, like a lateral extension 
of the uterus. In the beginning it has a doughy consistency. 
The inflammation has invaded the connective tissue sur- 
rounding the uterus, and may spread anteriorly alongside 
of the bladder to the extraperitoneal connective tissue, and 
even to the connective tissue of the thigh. It may extend 



DIAGNOSIS. 121 

laterally between the layers of the broad ligament to the 
hollow of the sacrum ; or it may go posteriorly, pushing 
up the serosa of Douglas' pouch and ascending behind the 
peritoneum, on the iliopsoas muscles, to the renal region. 

The tumor is found in some one of the foregoing posi- 
tions. It is an exudate in the pelvic connective tissue 
(phlegmon of the pelvis, pelvicellulitis, parametritis of 
Virchow), and consists of a mucoid swelling and round- 
cell infiltration of the connective tissue. (Plate 59, Fig. 
1 ; 61,2; 41, 2.) The exudate is usually absorbed, but 
scar tissue is left behind, which later binds down and 
displaces the uterus. 

If abscesses form, the pus may burrow its way into the 
rectum, into the vagina, into the bladder, through the sci- 
atic foramen, along the inguinal canal, or, lastly, through 
the abdominal wall, pointing above Poupart's ligament. 

The overlying peritoneum is usually in a condition of 
irritation, as is indicated by greater pain, meteorism, diar- 
rhea, and vomiting. The consequent adhesions of the 
pelvic organs cause sterility. If the peritoneum allows 
the exudate to escape, a fatal perforative peritonitis will 
follow. (Plate 39.) 

In circumscribed parametritis there may be localized 
abdominal pain (from the irritation of the serosa), but the 
violent general pains, the tympanites, and the intraperi- 
toneal exudate are absent. The space of Douglas also 
remains free. Alongside of the uterus there is at first a 
hypersensitiveness, then increased resistance, and finally a 
parametritic tumor of doughy consistency. 

For the differential diagnosis from tumors of the pouch 
of Douglas see § 35. 

The diagnosis of peritonitis is based upon the demon- 
stration of an exudate. (Plate 58, Fig. 1.) As long as 
the process is limited to the pouch of Douglas and is 
walled off by adhesions at the pelvic inlet (a pelveoperi- 
tonitis), the prognosis is far more favorable than when the 
entire peritoneal cavity is involved. 



122 SEPSIS. 



PLATE 41. 

Fig. 1. — Acute Purulent Parenchymatous and Interstitial 
Salpingitis. Not only the papillae are proliferated, but also their 
stroma (1) and the connective tissue of the subniucosa (3), and the 
muscularis (4 and 5) is infiltrated with round cells. The epithelium 
is partly swollen and partly cast off, the excoriated papillae adhering 
and forming small cysts (2). (Original drawing from a specimen. ) 

Fig. 2. — Parametritis Acuta of the Broad Ligament. Both 
the connective-tissue fibers and the areolar tissue are infiltrated with 
round cells. This first stage of swelling and suppuration passes later 
into the second stage — the transformation into scar tissue. Contrac- 
tion occurs. (Original drawing from a specimen. ) 

Fig. 3. — Chronic Oophoritis with Oligocystic Degeneration. 
(See Plate 45 and Fig. 35. ) The inflammatory disturbances lead to a 
thickening of the tunica albuginea, producing a cystic swelling of the 
follicles ( 1 and 2 ) ; the follicular epithelial cells desquamate ( 10 ) and 
the ova die. The older corpora lutea become transformed into corpora 
fibrosa (8) (or candicantia). Eecent hemorrhages and older ones 
with blood pigment (9) are found in the stroma (13). The tortuosity 
(5) of the vessels (4) is a physiologic peculiarity of the ovary; in 
places perivascular round-cell accumulations can be seen (6). The 
follicles are surrounded by the tunica fibrosa (7); the surface of the 
ovary is covered with cuboid germinal epithelium (3). (Original 
drawing from a specimen. ) 

As an intermediate stage we sometimes observe acute 
oophoritis or salpingitis in the shape of swollen, exquisitely 
sensitive adnexa, in the bimanual palpation of which the 
greatest gentleness must be exercised in order to avoid the 
rupture of an abscess or the destruction of an existing 
encapsulation. (Plates 39, 44, 59, Fig. 3.) 

General peritonitis may follow an acute or a chronic 
course ; the latter is designated as peritonitis pyofibrinosa, 
and has a more favorable prognosis. 

The onset of the inflammation is marked by a pro- 
tracted chill, and is followed by diffuse abdominal pain. 
The abdomen may be so tympanitic and distended that 








c?- 










: Or- 









• 6^ 




u 



TREATMENT. 123 

dyspnea is caused by the pushing-up of the diaphragm. 
"Vomiting and constipation are present, giving place to a 
profuse fetid diarrhea, Euphoria, together with a rapid 
rise of the respiratory and pulse-rates (not always of the 
temperature, however), is always suspicious. 

Treatment. — All disturbances of menstruation are to 
be avoided. Absolute asepsis is to be observed in all 
operative measures — therapeutic manipulations (sounds) 
and in the care of pessaries. The lighting-up of old 
inflammatory residues by exploratory procedures is par- 
ticularly to be avoided. 

Ulcers of the vulva are to be cauterized (formalin) and 
treated with iodoform, airol, nosophen, or iodoformogen, 
or protected by compresses soaked in oil of turpentine. 
The inflammatory edema is to be treated by moist appli- 
cations (solution of aluminum acetate). 

Ulcerations of the cervix are to be cauterized with for- 
malin and treated with irrigations of aluminum acetate, cor- 
rosive sublimate, or lysol. Dry powders may be employed 
to disinfect the parts, although this method is more trouble- 
some, because of the necessity of daily repetition. 

In acute endometritis and myometritis the patients, and 
especially the genital organs, should not be disturbed. 
The treatment consists of rest in bed, mild laxatives, 
w r arm fomentations, warm vaginal irrigations with potas- 
sium permanganate, weak solutions of lysol (0.25^), 
normal saline solution, or mucilaginous decoctions, using 
about a liter of fluid, carrying the tube high up (gently), 
and not elevating the douche bag very much. 

If the inflammation increases, the fomentations are to 
be replaced by frequently repeated cold applications or by 
the ice-bag or ice-coil. 

Abscesses should be opened only wdien they are easily 
accessible. They are usually situated in the parametritic 
tissues. 

Acute parametritis is to be treated with the ice-bag, 
calomel, and blue ointment (1.0 applied every two hours 



124 CHRONIC SALPINGITIS. 

PLATE 42. 
Double Pyohydrosalpinx, Chronic Adhesive Perimetritis 
and Oophoritis. Both tubes are almost filled with pus; the fimbri- 
ated ends, walled off: both from the isthmus and from the peritoneal 
cavity, are transformed into cysts. (Original drawing from a specimen 
of Professor Beck's. ) 

to the point of salivation), followed by warm fomentations 
and enemata. 

In acute peritonitis several ice-bags upon the abdomen 
and laxatives in the stage of constipation (infusion of 
senna; calomel — at first 0.2 to 0.5, later 0.05 to 0.1, 
at a dose). The diet should be liquid and nutritious. 
Stimulants, which should contain more alcohol when the 
patients are accustomed to wine or beer. As soon as free 
evacuations occur opium is given, or inunctions of blue 
ointment together with calomel in small doses. Free- 
diaphoresis is excited, and the activity of the skin is in- 
creased by cool sponging. [Cases of acute peritonitis 
should be carefully watched in order not to neglect opera- 
tive measures. Localized peritonitis with abscess forma- 
tion always indicates, and promptly responds to, surgical 
treatment. Acute diffuse peritonitis, however, will usually 
prove fatal, but that fact warrants early surgical treat- 
ment, although most cases succumb. — Ed.] 

\ 16. CHRONIC SALPINGITIS. 

Etiology. — For definition and anatomv see explanations 
to Plates 40-43, 44, 46, 59 (Fig. 3), and 74. The most 
frequent causes are puerperal and gonorrheal inflamma- 
tions ; in every case of endometritis the tubes are not 
necessarily involved. 

(a) Parenchymatous Catarrh of the Tubes (Plate 40, Fig. 1), 
with Atresia of the Ostia : Hydrosalpinx. 

The secretion accumulates in the abdominal portion, flattens the 
papillae of the mucous membrane and their cylindric epithelium, sepa- 



DIA GNOSIS.— TEE A T3IEXT. 125 

rates the muscle-fibers, and in this way thins and stretches the tubal 
wall. The tube is held by the serous duplicature of the broad liga- 
ment, and presents a spiral appearance with multiple constrictions, as 
shown in plates 42 and 44. Sometimes the hydrops tubse (profLuens) 
empties itself periodically into the uterus. 

Symptoms. — There are no characteristic symptoms 
worthy of mention, except anomalies of menstruation, 
sterility (since the disease is usually bilateral), pressure 
effects, and perisalpingitic pain. 

Diagnosis. — As long as pelvic exudates are absent, 
bimanual palpation reveals a round, fluctuating, trumpet- 
shaped tumor, peripherally swollen, extending from an 
angle of the uterus, and not rarely lying in the vesico- 
uterine space. The exclusion of a tumor of the ovary is 
important. (Plate 74.) 

Treatment. — In an extreme degree of swelling, celio- 
salpingotomy, for the purpose of removing the tubal sac ; 
or salpingostomy : i. e., restoration of the lumen of the 
tube by opening the ostium abdominale and stitching the 
serosa to the mucosa. 

(b) Parenchymatous and Interstitial Purulent Inflamma= 
tion of the Tubes (Plate 41, Fig.l), with Atresia of the Ostia : 
Pyosalpinx. (Plate 40, Fig. 3 ; Plates 42 and 44 ; Plate 59, Fig. 3 ; 
Plate 74. ) 

The tube is bluish-red and thickened, not only from a 
passive dilatation, but also not rarely from proliferation of 
the muscularis. The inflammatory process passes either 
through the abdominal ostium or through the tubal wall to 
the peritoneal covering, and thence to the pelvic peritoneum 
and ovary. It always remains circumscribed, the organs 
contracting adhesions that often contain purulent deposits. 
The gonorrheal inflammation is usually bilateral. 

We differentiate histologically : 

1. Acute catarrhal parenchymatous salpingitis with pro- 
liferation of the epithelium. 

2. Acute purulent parenchymatous and interstitial salpin- 
gitis with partial desquamation of the epithelium and in- 
flammatory infiltration of the stroma. 



126 CHROXIC OOPHORITIS. 

PLATE 43. 
Chronic Adhesive Perimetritis and Salpingitis with Uterine 
Myomata. A cross-section shows the marked thickening of the tubal 
wall and exposes to view the unopened ovarian abscess, which is adher- 
ent to the tube. (Original water-color. ) 

3. Chronic interstitial salpingitis, contraction from the 
connective tissue that replaces the muscularis. The tube 
loses its elasticity. 

From agglutination of the tubal ostia the first class 
of cases gives rise to hydrosalpinx ; the second and third, 
to hematosalpinx and pyosalpinx. 

Symptoms. — Pain at the side of the uterus, becoming 
worse at the menstrual epoch and when the intra-abdomi- 
nal tension is increased. Sterility, from the usual combi- 
nation with oophoritis. Fever (in gonorrhea, only after 
exertion or excitement). 

Prognosis. — Conception is impossible. The patient is 
always threatened with peritonitis from perforation. Gon- 
orrheal pyosalpinx does not rupture easily ; the septic form 
does. 

Diagnosis, — By bimanual palpation. (See the differen- 
tial diagnosis of the retro-uterine tumors under Ovarian 
Cystomata, and Plate 74, Figs. 1 and 2, and Plate 59, 

Treatment. — Celiosalpingectomy, stitching the pus sac 
to the abdominal wall (Hegar, Kaltenbach) and pressing 
up the uterus from the vagina (Gusserow) are indicated. If 
the pyosalpinx is not adherent, its rapture can usually be 
avoided. 

If there is distinct fluctuation in the vagina or abdominal 
wall, free incisions should be made and iodoform gauze 
drainage established. (See Chronic Pelviperitonitis.) 

§ 17. CHRONIC OOPHORITIS. 
Etiology. — Suppurative oophoritis, due to lymphatic 



Tab. 43. 




LUh. Anst E Reichiuild, Miuichm. 



ETIOLOGY. 



127 



absorption from the uterus and tubes, and caused by trau- 
matic or operative septic infection, has been mentioned in 
connection with peritonitis in a preceding section. 

Ovarian abscesses, however, usually follow purulent 




Fig. 34. — Senile cirrhotic atrophy of the ovary. 




Fig. 35. — Oligocystic degeneration of the ovary. 

inflammations of the tubes. (Fig. 36.) This oophoro- 
salpingitis is combined with perimetrosalpingitis, peri- 
metro-oophoritis, and pyosalpinx, forming, together with 
encapsulated ovarian and peritoneal pus sacs, a large ag- 



128 CHRONIC OOPHORITIS. 

PLATE 44. 

Pelvic Peritonitis, Perioophoritis, Perisalpingitis and Right= 
sided Pyosalpinx. View of the pouch of Douglas. Pseudoliga- 
inents fix the uterus aud its aduexa to the sigmoid flexure. The left 
tube is beut at an angle, the right tube shows inflammatory redness, 
and is transformed into a pyosalpinx by the agglutination of the ab- 
dominal ostium. The globular divisions of the tumor are character- 
istic. (See Plates 40, 42, 59, 74.) . (Original water-color.) 

glutinated tumor (pyo-oophorosalpinx). As in purulent 
salpingitis, the cause is to be found in a septic or gonor- 
rheal mixed infection. 

Sclerotic oligocystic ovarian degeneration (Plate 45 ; 
Plate 41, Fig. 3 ; and Fig. 35), may occur alone, leading 
to destruction of all the follicles, so that the organ becomes 
hypertrophic, cicatrized, and dense from the formation of 
chronic inflammatory connective tissue. (Plate 44 and 
Fig. 34.) 

Symptoms. — These are clue partly to the uterine phe- 
nomena of dysmenorrhea and partly to hysteria. 

The predominant symptom is pain, felt in the lumbar 
and pelvic regions and radiating to the groins and thighs. 
This pain increases at the menstrual periods, which are 
very irregular, sometimes oligomenorrhea or amenorrhea, 
sometimes menorrhagia, being present. It occurs far less 
often as intermenstrual pain. It is increased by exertion 
and constipation, and may present itself as a tubal colic. 

Diagnosis. — A hypersensitiveness of the adnexa may 
be found by bimanual examination ; the tube is swollen, 
and the ovary is enlarged. These organs should be care- 
fully palpated by the methods demonstrated in Plates 21- 
23. The ovary is frequently dislocated and bound down 
behind and below the uterus. (Plate 19, Fig. 1.) 

One must not be misled by tenderness of the overlying 
parts. In lumbo-abdominal neuralgias the belly wall is 
hypersensitive ; certain hysteric affections (" ovarie " of 




/ 



SYMPTOMS.— TREATMENT. 



129 



Charcot) may give rise to pain in a healthy ovary, or in the 
neighboring portions of the broad ligament or vaginal vault. 
In perimetrosalpingitic processes the individual organs 
can not be differentiated. 




Fig. 36. — Adhesive perioophorometrosalpingitis. The entire poste- 
rior peritoneal surface of the uterus and the broad ligaments is covered 
by adhesions. They form a pocket in 'which the ovary was completely 
concealed. It was only by holding up the ovary by means of a thread 
that it was rendered visible in the illustration. The fimbriated end 
of the tube is completely occluded and destroyed by the flap-shaped 
adhesions. An analogous case is described in the "Mon. f. Geb.," 
1898, in which the ovary was still more freely movable, and could be 
distinctly palpated as it slipped in and out of a similar pocket. 
(Photograph from an autopsy at the Heidelberg Path. Inst.) 



Treatment. — Avoid injurious congestions by abso- 
lute rest in bed, by sexual continence, and by securing 
regular evacuations of the bowels and bladder. 
9 



130 CHROXIC OOPHORITIS, 



PLATE 45. 

Fig. 1. — Pelvic Peritonitis. The uterus is displaced anteriorly 
and to the left. Adhesions bind it to the bladder and intestine and 
fix the tubes and ovaries. The left ovary is enlarged, and shows 
oligocystic degeneration : i. e. , all the follicles become cystic, with des- 
quamation of the germinal epithelium and destruction of the ova. 
(See Plate 41, Fig. 3, and Fig. 35.) The other ovary is not enlarged, 
and has a scarred surface from frequent ovulation. (Fig. 34.) These 
plastic inflammations are due to gonorrheal salpingitis, or to metritis 
or parametritis from puerperal or operative lesions of the genital mu- 
cous membrane. They may start in other organs and sink down into 
the pouch of Douglas, which is the lowest space in the abdomen. 

Fig. 2. — Left=sided Dermoid Cyst Perforating into the 
Rectum. (Original drawing made from the data obtained in palpat- 
ing a case in the Munich Frauenklinik.) The hair contained in the 
tumor passes into the rectum through the perforation. Dermoid cysts 
occur most frequently in the ovary, and contain sebaceous matter, hair, 
teeth, or even complicated organic structures (brain and nerve masses, 
portions of the eye, mandible with teeth, etc). (See Plate 79, Fig. 4.) 



Removal of the original cause : Treatment of the uter- 
ine inflammation, vaginal irrigations, but no intra-uterine 
treatment. 

For the pain : Rest in bed ; the ice-bag, which may be 
subsequently replaced by warm fomentations and baths. 
In certain cases hot vaginal irrigations (117° to 122° F.) 
or hot sand-baths are of value. If the patient is up 
and about, the organs are to be supported by Mayer's 
ring (the lever-pessaries press upon the diseased adnexa), 
or vaginal tamponade (the fornix especially) with iodoform 
gauze, or depletives, such as potassium iodid, ichthyol, or 
glycerin, in vaginal suppositories or upon tampons, 

If the pain is unbearable or if frequent elevations of 
temperature occur : Removal of one or both ovaries, 
usually with the corresponding tube. When the pelvic 
organs are completely agglutinated, the adhesions con- 
sisting of rigid scar tissue, the uterus also is to be re- 



Tab. 45. 




V 








CHRONIC PELVIC PERITONITIS. 131 

moved. Ovariotomy is indicated only when persistent 
treatment for years has failed. 

If all the subacute phenomena have disappeared (occa- 
sional chilliness, great pain), massage and compression are 
useful. 

1 18. CHRONIC PERIMETRITIS, OOPHORITIS, AND SAL= 
PINGITIS. CHRONIC PELVIC PERITONITIS. 

Anatomy. — See explanations to Plates 40-45 ; 59, 
Fig. 3 ; 74, and Diagnosis of Pyosalpinx. 

Etiology. — In chronic pelveoperitonitis the tube is by 
far the most frequent avenue of infection (mostly gonor- 
rheal) ; small quantities of serum, mucus, or pus escape 
from the ostium abdominale. The infection may also 
occur through the lymphatics. Genital tuberculosis is a 
not infrequent cause. 

Catarrhal salpingitis gives rise to perimetrosalpingitis 
serosa ; purulent salpingitis, to purulent pelveoperitonitis 
saccata. Suppurating tumors (dermoids) furnish an occa- 
sional source of infection. 

Symptoms and Prognosis. — Sudden violent pelvic 
pain (from the escape of pus into the abdominal cavity), 
with chill, vomiting, tympanites, small pulse, and drawn 
features. The temperature rises and assumes a remittent 
character. There are rectal and vesical disturbances, 
pericystitis, and periproctitis. If an abscess breaks 
through into the bladder, sharp pain and purulent cystitis 
result. 

The fever declines as the exudate becomes encapsu- 
lated ; the chills reappear, however, as soon as the per- 
foration of a hollow viscus is threatened. 

The premonitory symptoms are intestinal tenesmus, 
vesical pain, and foul-smelling feces and urine. 

When perforation has occurred, the process has by no 
means terminated ; from now on there are periods of 
euphoria, alternating with chills and purulent discharges, 
the patient becoming gradually weaker — " hectic fever." 



132 CHRONIC PELVIC PERITONITIS. 



PLATE 46. 

Genital Tuberculosis of Both Tubes (the Right One Cut 
Open), of Both Ovaries, and of the Pouch of Douglas. (Orig- 
inal water-color from a specimen. ) 



Perforation into the peritoneal cavity is rarely followed 
by immediate death. 

In relatively favorable cases the encapsulated exudate 
becomes absorbed (peritonitis indurata), but from the 
numerous adhesions, and consequent organic displace- 
ments and irritations, there remain serious permanent 
disturbances of health — sterility (abortion, extra-uterine 
pregnancy), hysteria, menstrual colic, menorrhagia, and 
profuse discharge. The gonorrheal inflammation is espe- 
cially liable to recur. 

Diagnosis. — In addition to the hypersensitiveness of 
the abdomen and of the vaginal vault, bimanual examina- 
tion causes marked pain, especially on moving the uterus. 

The adhesions are recognized from the fact that the 
uterus has lost its range of motion, being bound down in 
some pathologic position. (See Displacements of the 
Uterus and accompanying plates.) 

Exudates never exist without peritoneal pain, fever, etc. 
They are usually found in the pouch of Douglas, and may 
be palpated from the rectum or from the posterior vaginal 
vault. The adnexa are embedded in the exudate. (See 
Eetro-uterine Tumors under Ovarian Cystomata.) If the 
pouch of Douglas is obliterated, the exudate occurs above 
the pelvic inlet — in the iliac fossae. In other cases the 
mass may reach as high as the umbilicus. 

Treatment. — The acute form is discussed in § 16. In 
the chronic form every therapeutic manipulation of the 
genitalia is contraindicated. This includes the introduc- 
tion of pessaries and of the mtra-uterine sound, scarifica- 
tion of the cervix, prolonged bimanual examination, etc. 



CO 
OS 







§ 



\ 







\ 






TREATMENT, 133 

Uterine catarrh is to be disregarded ; abscesses are to be 
opened only when perforation is threatened. 

Frequent rest, sexual abstinence, and rather liquid 
stools are to be secured. For the pain and fever : hori- 
zontal position, warm fomentations, lukewarm vaginal in- 
jections of mucilaginous or narcotic solutions, introduction 
of vaginal suppositories containing anodynes (cocain, 
extract of belladonna, morphia). Later, warm sitz-baths 
(99° F. and gradually cooler). 

To stimulate absorption : Compression, hot vaginal in- 
jections (117° to 126° F.). Absorbents, such as potas- 
sium iodid, ichthyol, iodoform, glycerin tampons, mud 
baths, salt baths (Kreuznach, Xauheim, Oeyuhausen, 
Tolz). Adhesions may be stretched at first by rectal in- 
jections (as recommended by Hegar, gradually increasing 
amount and decreasing temperature) ; later, if the parts 
are absolutely painless, massage. (See Plates 21—23.) 

In tubercular peritonitis : Simple celiotomy, with or 
without applying iodoform to the serosa. The opening of 
the abdominal cavity by posterior colpotomy has proved 
of value (Lohlein). 

In gonorrheal peritonitis : Removal of pyosalpinx and 
diseased ovaries, as far as enucleation is possible. If pelvic 
abscesses cause an increasing impairment of the general 
health, they must be enucleated or freely drained. 

The parts may be best surveyed after a celiotomy. A 
conclusion may then be drawn as to whether it is better to 
open and drain the abscess from the vagina, or through the 
abdominal wall. 

The posterior vaginal vault may be directly incised, and 
the thickened peritoneum stitched to the vaginal mucosa. 
There is danger of infection from putrefactive organisms 
from the rectum. 

If perforation into the bladder occurs, it may be neces- 
sary to establish a vesical fistula, either suprapubic or 
vaginal. 

If the abscess, with or without vaginal fistula, has old, 



134 CHRONIC PARAMETRITIS. 



PLATE 47. 

Cystitis; Ureteritis (Pyonephrosis) as a Result of Lithi= 
asis; Metritis with Endometritis Fungosa; Cervicitis with 
Marked Dilatation of the Cervical Canal ; Vaginitis. The 

bladder is dissected away and displaced to the left; its hyperemia 
mucous membrane and thickened walls are exposed to view. On the 
right may be seen the ureter, cut across near its insertion into the 
bladder. It shows inflammatory redness at this point, while just 
above there is an ulceration from which an impacted phosphatic calcu- 
lus (depicted below) was removed at autopsy. The ureter was mark- 
edly dilated above this point, as a result of the obstruction and of the 
congestive narrowing of the canal at its entrance into the bladder. 
The endometrium shows marked proliferation and edema; the mucous 
glands and the uterine cavity are filled with mucus. In the cervical 
canal a tough mucous plug has been left in position, covering the nar- 
row external os. The internal os is also quite narrow. The vaginal 
mucous membrane is inflamed. (Original water-color from a specimen 
at the Heidelberg Path. Inst. ) 

hardened walls difficult of removal through an abdominal 
wound, vaginal hysterectomy (Landau, Pean) ; drainage. 



£ 19. CHRONIC PARAMETRITIS (PHLEGMON OF THE 
BROAD LIGAMENTS) AND PARACOLPITIS. 

There are two forms : 

(a) A chronic process, arising from the acute parametritis 
just described. 

(6) Atrophic chronic parametritis (Freund). 

Etiology. — (a) See § 15. (b) Overstimulation of the 
genital nerves by prolonged and profuse secretion (fre- 
quently repeated pregnancies, with lactation during the 
intervals, sexual excesses). Following upon periphlebitic 
processes, a connective-tissue change resembling cicatricial 
atrophy commences in the base of the broad ligament and 
gradually involves the entire genital tract. 

Symptoms and Diagnosis. — (a) An acute parametritis 



I 



mpmtft pjoyi/mx ;.; jsvyynj 




It 



X. 



'if q^x 



SYMPTOMS.— TREATMENT. 135 

that has become chronic may take one of the following 
courses : The exudate may become thick, remaining for 
months or years ; it may perforate, and, as it has not 
entirely undergone suppuration, it may discharge from 
time to time ; or, more frequently, it may undergo absorp- 
tion and cicatricial contraction. These contractions may 
also follow scars from noninfected interstitial lesions 
during delivery. They result in displacements and dis- 
tortions of the uterus and its adnexa. (See § § 9 to 1 1 and 
Plates 23 ; 41, 2 ; 55, 1 ; 59 ; 62.) These masses of scar 
tissue are less sensitive than those due to perimetritis. 
They may be found about the vaginal fornices or alongside 
of the uterus ; the sacro-uterine ligaments may be shortened, 
limiting range of motion of the uterus. 

(6) Symptoms of parametritis chronica atrophicans : Spon- 
taneous pelvic pain and tenderness of the bladder and 
rectum if their surrounding connective tissue is involved 
in the process. Abrogation of the sexual functions : 
oligomenorrhea and dysmenorrhea. Nervous irritability, 
depression, hysteria, and disturbances of general nutrition. 

It is difficult to move the organs about in the sensitive 
and firm connective tissue. 

Treatment. — (a) Chronic septic parametritis : Abscesses 
are to be incised only when they give rise to fluctuation 
beneath the skin or mucous membrane, as in chronic pel- 
veoperitonitis. Absorption is to be stimulated by potas- 
sium iodid, glycerin, ichthyol, iodoform, hot vaginal 
injections, Hegar's enemata, mud-baths, and hot sand-baths. 
Massage is indicated in some cases. Elastic traction on 
the cervix by means of a bullet-forceps is occasionally 
of some benefit. No intra-uterine operations should be 
performed. Secure easy and regular evacuations of the 
bowels. 

(6) Parametritis atrophicans : Hot vaginal douches and 
sitz-baths ; massage ; repeated mechanical intra-uterine 
stimulation and mild intra-uterine irrigations (soda, 
Fritsch) are measures to be employed, 



136 GENITAL TUBERCULOSIS. 



PLATE 48. 
Chronic Cystitis with Acute Exacerbations. Mucous mem- 
brane atrophic, partly necrotic, and thrown into plump, rigid folds by 
the marked thickening of the bladder- wall. (Original water-color 
from an autopsy at the Heidelberg Path. Inst. ) 



i 20. GENITAL TUBERCULOSIS. 

Definition and Etiology. — The infection with the 
tubercle bacillus may be primary or secondary ; the latter 
is the more frequent. On the whole, genital tuberculosis 
is rare. Gonorrheal, septic, and mixed infections favor its 
development. 

Primary infection may result from cohabitation with a 
man who has genital tuberculosis, from an infecting digital 
examination, from infected linen, etc. 

Secondary infection may occur by metastasis from the 
intestines or from the lung, by infection of the tube from 
the peritoneum (the most frequent cause), or from the ad- 
hesion of a tubercular loop of intestine. 

The mucous membrane of the tube is by far the most 
easily infected ; the process readily extends from here to 
the ovaries (by way of the peritoneum, according to 
Schottlander), or, less rarely, to the uterine mucous mem- 
brane, the menstrual changes evidently interfering with 
the deposit of the bacilli. The cervical and the vaginal 
mucosa are very rarely affected, the former being protected 
by its secretion, the latter by its dense epithelium. Here, 
as in the vulva, fissures form the sole avenues of entrance 
for the primary invasion of the bacilli. 

Tuberculosis of the vesical mucosa, following a general 
or a genital tuberculosis, is not of more frequent occur- 
rence. 

Anatomy. — (1) General peritoneal tuberculosis, which also affects 
the genital serosa; (2) tuberculosis of the tubes, ovaries, or corpus 
uteri; (3) the very rare affections of the cervical and vaginal mucosa; 
(4) the lupous forms seen on the vulva. 



Tab. 48. 




Lith.Anst EReichhold, Miinchen. 



PATHOLOGY.— DIAGNOSIS. 137 

Subacute aud chronic inflammatory phenomena (ascites, serofibrin- 
ous exudate, formation of pseudoligaments ) occur, and the peritoneum 
becomes covered with tubercles. The tubes are fixed in the pouch of 
Douglas and their ostia are agglutinated. As the caseous secretion 
can not be discharged, a pyosalpinx is formed. The walls are red- 
dened, thickened, and infiltrated with yellow tubercular granulations. 
Caseous areas, very rarely miliary tubercles, are found in the ovaries; 
they seem to arise most frequently in the stroma. Schottlander also 
found follicular tuberculosis experimentally ; he further found micro- 
scopic tubercular changes in the apparently healthy ovaries of tuber- 
cular women. 

The cylindric epithelium is at first well preserved, only a few cells 
showing mucoid and granular degeneration. The epithelial layer, 
however, is finally replaced by a caseous coating, and the muscular is is 
infiltrated with granulation tissue containing giant cells. The vessels 
show chronic inflammatory and hyaline changes. Koch's bacilli may 
be demonstrated, although sparingly present. 

In uterine tuberculosis the wall is thickened by the edema of the 
muscularis; the mucous membrane is totally destroyed and is trans- 
formed into a caseous mass; scattered tubercles may be seen. The 
ulcerative process is sharply limited at the internal os. 

Tuberculosis of the vagina and cervix likewise presents irregular 
ulcerations surrounded by tubercles and a dirty yellow exudate. 

Lupus vulvae usually commences on the labia as small, flat, reddish 
tumors, which ulcerate. Although they infiltrate more diffusely, they 
do not extend so rapidly nor secrete so profusely as do syphilitic ulcers. 
The scars are reddish-violet. The microscope shows no hypertrophy 
of the papillse and skin, but a small-cell infiltration about the vessels. 

Tuberculosis of the bladder occurs as tubercular infiltration or in 
the form of ulceration. 

The symptoms and diagnosis of the tubal affections 
are the same as those of salpingitis or pyosalpinx. 

Uterine tuberculosis produces the same phenomena as 
ordinary metritis, but the organ enlarges more quickly and 
to a greater degree. The discharge is caseous. The dif- 
ferential diagnosis, from corporeal carcinoma especially, 
may be aided by curetment, but it is by no means easy : 
giant cells, tubercles, demonstration of bacilli, or inocula- 
tion of the peritoneal cavity of a rabbit with the uterine 
secretion. An accompanying tubal affection is strong cor- 
roborative evidence. 

In the beginning of the disease there is amenorrhea, 
interrupted by blood-tinged or mucopurulent discharges, 
and a sensation of weight and pressure in the pelvis. 



138 GENITAL TUBERCULOSIS. 



PLATE 49. 

Fig. 1. — Syphilitic Ulcer of the Vaginal Cervix. Lardaceous 
exudate ; swollen, markedly and sharply cut edges. General inflam- 
matory hyperemia of the cervix. (From Mracek. ) 

Fig. 2.— Syphilitic Ulcers of the Vaginal Mucosa. Typical 
| — |-form, the vaginal walls coming in contact. (From Mracek.) 

Iii vulvar, vaginal^ and cervical tuberculosis the bacilli 
are to be demonstrated, the microscopic changes in ex- 
cised pieces studied, and the general condition of the 
patient taken into consideration. 

Peritonitis. — Ascitic fluid of a high specific gravity, straw-yellow 
color — exploratory laparotomy shows confluent tubercles. It must, 
nevertheless, be remembered that some forms of chronic peritonitis 
of nontubercular origin show confluent nodules. 

Prognosis. — Grave, just as in tuberculosis of the uro- 
poietic apparatus. If an organ is primarily affected, it 
may be extirpated. We are not yet sufficiently acquainted 
with the ultimate results from these operations. 

Treatment. — Extirpation with a good result is possible 
(Hegar, AVerth, Pean) if the disease is limited to the 
tubes and uterus ; if there are no tubercular peritoneal 
pseudomembranes ; and if the general condition, of the 
lungs especially, will allow of the operation. 

If only the tubes are diseased, they are to be removed, 
together with the ovaries, by celiotomy. The peritoneal 
cavity is protected from infection by bringing the tumor 
outside of the abdominal wound and using elastic ligatures. 
If the hemorrhage is uncontrollable, incise the posterior 
vaginal vault and pack Douglas' pouch w T ith iodoform 
gauze (Wiedow). 

If the uterus is affected as well, and is not too volumi- 
nous, removal per vaginam should be practised. 

If contraindications exist, the pyosalpinx is to be 
opened from the vagina and drained with iodoform gauze; 



\ 



ICj 








TREATMENT.— VENEREAL DISEASES. 139 

the uterus is to be cureted and the raw surface covered 
with iodoform (iocloform-blower). 

Vaginal ulcers and vulvar lupus are to be excised or 
cauterized with the hot iron, fuming nitric acid, or caustic 
potash, and dusted with iodoform. 

Tuberculosis of the peritoneum is treated by celiotomy. 

Ulcers of the bladder : First determine the condition 
of the kidneys. A suprapubic cystotomy is performed, 
the ulcers are excised, and the wound is packed with iodo- 
form gauze until it closes spontaneously. [The facility 
with which circumscribed areas of ulceration may be 
treated through the endoscope renders cystotomy less fre- 
quently necessary. — Ed.] 



g 21. VENEREAL DISEASES. 

i. Ulcus Molle (Soft Chancre). 

Diagnosis. — These round, multiple, sharply circumscribed ulcers 
occur in from one to four days after exposure, and usually affect the 
vulva, occurring at the position of a small tear or herpetic ulceration. 
They are rare in the vagina and upon the cervix. The ulcer is bathed 
in pus; its edges are undermined, soft, and reddened. It may be the 
seat of diphtheric inflammation or of a rapid destructive ulceration — 
ulcus gangramosum. It may heal at the point of infection (as usual 
with a scar), yet spread further by serpiginous ulceration. 

The infection is a local one, stopping at the inguinal glands, which 
undergo suppuration (chancroidal bubo) and are very sensitive. 

Treatment. — Cauterize the ulcer with fuming nitric acid or chromic 
acid and treat it antiseptically. Buboes are either to be freely incised 
or enucleated, and dusted with iodoform. 



2. Ulcus Durum (Hard Chancre) ; Syphilis. 

Diagnosis. — The first lesion is a small, single ulcer, in which a 
papule develops three or four weeks after exposure. Its characteristic 
peculiarity is that it neither heals nor grows larger, but becomes sur- 
rounded by a hard infiltration. Its most frequent situation is upon 
the posterior commissure, and, next in order, upon the cervix, but it 
also occurs in the vagina. (Plate 49.) 

As a secondary affection, multiple, indolent, inguinal buboes ap- 
pear, which do not suppurate (differential point from the nonsyphilitic 
buboes). The infection spreads from here to the abdominal glands. 
Flat condylomata appear on and about the vulva, extending to the 



140 CYSTITIS. 



PLATE 50. 



Papular Gummata of the Vulva, of the Anus, and of the 
Inner Side of the Thigh. Some of them show areas of central 
necrosis. (From Mracek. ) 



thighs and anus. These are secondary proliferations (Plate 50), having 
the same structure as the primary papule (dense alveolar infiltration 
of the cutis with cells rich in nuclei ; chronic inflammatory thickening 
of the vessel-wall, with narrowing of the lumen). 

Tertiary syphilides rarely occur; gummata are usually situated 
in the vagina and beside the cervix. They disintegrate rapidly, 
and strongly resemble the flat ulcerating vaginal epithelioma. (Plate 
50.) 

The differential diagnosis has been given to insure clinical recog- 
nition. The treatment properly belongs to the domain of syphilog- 
raphy. 



$ 22. CATARRH OF THE BLADDER AND CYSTITIS. 

Anatomy. — Vesical catarrh occurs in an acute and in a chronic 
form. The latter arises either from the former or from a chronic 
hyperemia, which produces ecchymosis in the mucous membrane or 
hemorrhages into the bladder. 

In acute catarrh the organ is contracted; the mucosa is reddened, 
and shows areas that have lost their epithelium. Epithelial debris 
and emigrated red and white blood-corpuscles may be found between 
the folds of the wrinkled mucous membrane. 

If the inflammation has become chronic, there is a reddening of the 
entire mucous membrane, or an insular hyperemia (often about the 
internal urethral orifice, associated with small eechymoses). Great 
numbers of leukocytes pass out through the dilated vessels; the 
mucosa secretes quantities of mucus and casts off its superficial 
( squamous ) epithelium . 

If the catarrh decreases, the leukocytes continue to migrate for a 
long time ; in other cases permanent excoriations are established, which 
are converted into ulcers ( most frequently in the trigonum or at the 
urethral orifice) by the action of bacteria. The muscularis is finally 
affected. 

The original infiltration of the muscularis leads either to an acute 
extension of the inflammation, to cystitis, and even pericystitis (/. e., 
inflammation of the vesical subserosa and serosa), or to a chronic 
parenchymatous hypertrophy of the muscularis. The entire bladder- 
wall is thick and rigid. ( Plate 48. ) 

The serosa reacts in a like manner and protects the peritoneal cavity 
from the urine; if it does not, the most acute peritonitis sets in and 



t 






# 











fa 






ETIOLOGY. 141 

death follows. Such pernicious extension is brought about by pro- 
gressive gangrene. If the necrosis is limited to the mucous membrane, 
it leads to casting-oS of the same in toto or in shreds — cystitis diph- 
theritica. 

Etiology. — The manner of origin differs in many re- 
spects from that in the male. The shortness of the 
urethra allows the infective material to penetrate into the 
bladder more easily, and yet the same peculiarity prevents 
the urethritis from becoming chronic and going on to the 
formation of strictures. Concretions as large as a cherry 
may pass the urethra, and still larger ones may be removed 
through it by operative means. The female has no pros- 
tate, the hypertrophy of which leads to stasis and decom- 
position of the urine. The puerperal process gives rise 
to a series of injurious influences, partly direct pressure 
effects and partly inflammations. The latter are due either 
to direct extension from a parametritis or perimetritis, or 
to the perforation of an exudate or an extra-uterine gesta- 
tion sac. An analogous predisposition is seen in perforat- 
ing tumors of the female genitalia (carcinoma, see Plates 
85, 86, 88, 89 ; dermoid cysts). 

Retention of urine is another cause of catarrh of the 
bladder. It may be due to incarceration of a retroflexed 
gravid uterus, to an impacted retro-uterine tumor, or to an 
inversion of the vagina, with cystocele. The cause may be 
found in the bladder itself — tumors of the wall or vesical 
tuberculosis. 

The two most frequent causes, however, are direct 
infection from a dirty catheter and gonorrheal urethritis. 

Bacteria are concerned in all vesical catarrhs ; they in- 
jure the bladder-wall and cause decomposition of the urine, 
which irritates the mucous membrane. The catarrh is 
maintained by irritating urinary ingredients, such as alco- 
hol and cantharides. 

Symptoms and Diagnosis. — Increased frequency of 
micturition, ardor urinse, vesical tenesmus ; the urine is 
sometimes bloody and always contains more or less mucus 



142 CYSTITIS. 

(marked nubecula) or mucopus (thick, white sediment). It 
is cloudy and has a pungent ammoniacal odor. Slight 
fever is present. 

The microscope shows red and white blood-corpuscles, 
desquamated epithelium, and, if alkaline fermentation 
exists, crystals of triple phosphate and acid urate of am- 
monium. 

Diphtheric cystitis is recognized by the great vesical 
pain, the fever, and the shedding of membranes or shreds. 
The last-named symptom may render catheterization diffi- 
cult. If these membranes produce marked ischuria, 
symptoms of urinary retention (beginning uremia) appear 
— dyspepsia, nausea, vomiting, alternating constipation and 
diarrhea, and cerebral congestion. 

Hypertrophy of the bladder gradually leads to consider- 
able vesical dilatation from the rigidity of the walls ; 
even the empty bladder may be felt above the symphysis. 
After the muscular hypertrophy disappears the walls of 
the senile bladder may become almost as thin as paper — 
atrophy of the bladder. Both forms may be demonstrated 
by the catheter. 

The presence of a cystitis being established, its cause 
must be diagnosed. The vesical causes are ulcers, tumors 
(see under Tumors), concretions, and foreign bodies. 
Vice versa a whole series of troubles spring from inflam- 
matory irritation, especially of the urethra. The same 
is true of ulcers (tubercular and others) and fissures at 
the neck of the bladder, especially those situated at the 
internal orifice of the urethra and in the urethra itself. 
These are extremely sensitive, and often arise from cathe- 
terization (even with the elastic catheter). These fissures 
and the catarrh and many of its causes lead to the — 



SYMPTOMS. —DIA GNOSIS. 1 43 



Sequels of Cystitis. 

1. Vesical spasm. 

2. Paralysis of the bladder — paralysis vesicae (ischuria, 
incontinence, ischuria paradoxa, incontinence of reten- 
tion). 

I. Vesical Spasm is a neuralgia, and occurs in nervous 
women, either as a result of vesical catarrh, pericystitis, 
and all irritations of the bladder (foreign bodies ; concre- 
tions ; hemorrhoids ; ulcerations and fissures, especially at 
the vesical neck and in the urethra ; tumors), or as a 
primary neuralgia from the influence of severe irritations 
upon an easily excited nervous system. It reminds one 
of vaginismus, and the two conditions may be associated. 
It is possible that irritations of the internal genitalia may 
act as causal factors. Such irritations are overindulgence 
in sexual intercourse, onanism, interrupted coitus, strong 
emotions, probably, and colds with subsequent chronic 
hyperemia. When such primary conditions exist, irritat- 
ing foods and drinks may bring on an attack. Hysteria 
also plays its role. 

Symptoms and Diagnosis. — Violent attacks of pain, 
lasting from a few minutes to several hours, which radiate 
from the neck of the bladder, and sometimes assume an 
extremely painful spasmodic character, especially at the 
beginning of urination. This spasm may be so violent 
that the urine can not be voided (ischuria spastica). 

If a complicating vesical catarrh exists, the urine is 
cloudy, containing red and white blood-corpuscles, and 
mucus. In a pure neurosis it is as clear as water (urina 
spastica), but is frequently rich in urates and of such a 
peculiar offensive odor that some abnormal metabolic pro- 
cess (autointoxication) must be considered. The urine is 
sometimes passed in drops, sometimes in large amounts. 
The act excites radiating pain in all directions, as well 
as intestinal tenesmus, nausea, subsequent dyspepsia, ill 
humor, and sleeplessness, so that the general condition 



144 CYSTITIS. 

finally suffers. The paroxysms frequently appear irregu- 
larly ; the affection may persist for years. 

Diagnosis. — All causes must be excluded. Bimanual 
exploration (palpation between the vagina and the sym- 
physis) reveals the presence of calculi, tumors, and vesical 
hypertrophy. The sound, combined with the palpating 
vaginal finger, demonstrates sensitive areas (fissures) or 
small diverticula, the sacculations of which can not be 
emptied by the catheter, and thus continually reinfect the 
urine. The interior of the bladder may be digitally ex- 
plored. Cystoscopy (with or without dilatation of the 
urethra by means of Simon's specula) allows of inspection 
of the parts, showing the presence of tumors, ulcers, cir- 
cumscribed ecchymoses, small foreign bodies, and encysted 
calculi, and renders catheterization of the ureters possible. 
The latter procedure is of value in determining the source 
of pus that does not come from the bladder. 

Cystoscopy, as it has been perfected by the instruments 
of Casper, Nitze, Pawlick-Kelly, and Rose, is the newest 
aid to diagnosis. In difficult cases it is indispensable. The 
various methods of its application must be practically 
learned. The pelvis of the patient is elevated, the urethra 
is somewhat dilated (previous injection of a few centimeters 
of a 5^ solution of cocain), and a speculum with a 
beveled end is introduced. The bladder fills with air, and 
its walls, together with the urethral orifices, may be seen. 

In another method of cystoscopy at least 50 c.c. of a 
boric acid solution are injected into the bladder, and a 
catheter (not exceeding J of a cm. in diameter), armed 
with a small incandescent lamp, is introduced. By moving 
the instrument about, the numerous recesses of the female 
bladder, the interureteric fold, and the trigonum are ex- 
posed to view. By means of the operative cystoscope 
minor operations, such as catheterization of the ureters, 
may be performed. This method is particularly applicable 
to determine definitely the source of pus in unilateral 
pyonephrosis. 



VESICAL PARALYSIS. 145 

It should be mentioned that it is also possible, in the 
female, to separate the urines from the ureters by means 
of a double catheter, the dividing partition of which ex- 
tends to a position between the two ureteral orifices, and is 
pressed firmly against the bladder-wall. 

The ureteral orifices are seen as fine linear fissures, 
either upon the apex or at the sides of small elevations of 
the mucosa. 

Tubercular ulcers, developing tumors, threatened rup- 
ture of a parametritic or pericystic abscess, and encysted 
foreign bodies (vesical calculi) may be surely diagnosed, 
and to a certain extent treated, by means of the cystoscope. 

2. Paralysis of the bladder may be of a twofold char- 
acter : paralysis of the longitudinal and oblique muscular 
fibers — ischuria, retention of urine ; or paralysis of the 
circular fibers (sphincter vesicae) — incontinentia paralytica. 
Both forms may be combined : i. e., the urine dribbles and 
can not be retained (incontinence) after the desire to uri- 
nate has already been lost (ischuria). 

If paralysis of the sphincter is not present, in addition 
to the retention the bladder becomes immoderately dis- 
tended (without strangury), gradually overcoming the re- 
sistance of the sphincter and emptying its urine drop by 
drop. The bladder suffers no decrease in size, however, 
and the patient has no suspicion of its dilated condition 
(ischuria paradoxa, incontinence of retention). 

All these conditions (ischuria and incontinence) may 
follow the puerperal process, from displacements of the 
bladder, angulation of the urethra, swellings in the ureth- 
ral region after delivery, or from inflammation of any por- 
tion of the genital tract or its serous covering. They may 
be due to changes in the elasticity of the muscularis (fatty 
degeneration, atrophy) from cystitis, habitual overdistention 
of the bladder, advanced age, and acute infectious diseases. 
They are caused by decreased innervation, as seen in dis- 
eases of the spinal cord and other central disturbances, 
such as apoplexy, neurasthenia, and hysteria (after easy 
10 



144 CYSTITIS. 

finally suffers. The paroxysms frequently appear irregu- 
larly ; the affection may persist for years. 

Diagnosis. — All causes must be excluded. Bimanual 
exploration (palpation between the vagina and the sym- 
physis) reveals the presence of calculi, tumors, and vesical 
hypertrophy. The sound, combined with the palpating 
vaginal finger, demonstrates sensitive areas (fissures) or 
small diverticula, the sacculations of which can not be 
emptied by the catheter, and thus continually reinfect the 
urine. The interior of the bladder may be digitally ex- 
plored. Cystoscopy (with or without dilatation of the 
urethra by means of Simon's specula) allows of inspection 
of the parts, showing the presence of tumors, ulcers, cir- 
cumscribed ecchymoses, small foreign bodies, and encysted 
calculi, and renders catheterization of the ureters possible. 
The latter procedure is of value in determining the source 
of pus that does not come from the bladder. 

Cystoscopy, as it has been perfected by the instruments 
of Casper, Nitze, Pawlick-Kelly, and Rose, is the newest 
aid to diagnosis. In difficult cases it is indispensable. The 
various methods of its application must be practically 
learned. The pelvis of the patient is elevated, the urethra 
is somewhat dilated (previous injection of a few centimeters 
of a 5^ solution of cocain), and a speculum with a 
beveled end is introduced. The bladder fills with air, and 
its walls, together with the urethral orifices, may be seen. 

In another method of cystoscopy at least 50 c.c. of a 
boric acid solution are injected into the bladder, and a 
catheter (not exceeding J of a cm. in diameter), armed 
with a small incandescent lamp, is introduced. By moving 
the instrument about, the numerous recesses of the female 
bladder, the interureteric fold, and the trigonum are ex- 
posed to view. By means of the operative cystoscope 
minor operations, such as catheterization of the ureters, 
may be performed. This method is particularly applicable 
to determine definitely the source of pus in unilateral 
pyonephrosis. 



VESICAL PARALYSIS. 145 

It should be mentioned that it is also possible, in the 
female, to separate the urines from the ureters by means 
of a double catheter, the dividing partition of which ex- 
tends to a position between the two ureteral orifices, and is 
pressed firmly against the bladder-wall. 

The ureteral orifices are seen as fine linear fissures, 
either upon the apex or at the sides of small elevations of 
the mucosa. 

Tubercular ulcers, developing tumors, threatened rup- 
ture of a parametritic or pericystic abscess, and encysted 
foreign bodies (vesical calculi) may be surely diagnosed, 
and to a certain extent treated, by means of the cystoscopy 

2. Paralysis of the bladder may be of a twofold char- 
acter : paralysis of the longitudinal and oblique muscular 
fibers — ischuria, retention of urine ; or paralysis of the 
circular fibers (sphincter vesicae) — incontinentia paralytica. 
Both forms may be combined : i. e., the urine dribbles and 
can not be retained (incontinence) after the desire to uri- 
nate has already been lost (ischuria). 

If paralysis of the sphincter is not present, in addition 
to the retention the bladder becomes immoderately dis- 
tended (without strangury), gradually overcoming the re- 
sistance of the sphincter and emptying its urine drop by 
drop. The bladder suffers no decrease in size, however, 
and the patient has no suspicion of its dilated condition 
(ischuria paradoxa, incontinence of retention). 

All these conditions (ischuria and incontinence) may 
follow the puerperal process, from displacements of the 
bladder, angulation of the urethra, swellings in the ureth- 
ral region after delivery, or from inflammation of any por- 
tion of the genital tract or its serous covering. They may 
be due to changes in the elasticity of the muscularis (fatty 
degeneration, atrophy) from cystitis, habitual overdistention 
of the bladder, advanced age, and acute infectious diseases. 
They are caused by decreased innervation, as seen in dis- 
eases of the spinal cord and other central disturbances, 
such as apoplexy, neurasthenia, and hysteria (after easy 
10 



146 CYSTITIS. 

labors, simple operations that do not even involve the 
vesical region or anterior vaginal wall, emotion, ingestion 
of irritating foods, new wine and beer, asparagus, strong 
tea, etc.). Finally, they are seen in weak individuals, in 
the form of enuresis nocturna, and associated with intoxi- 
cations. 

Symptoms and Diagnosis. — Ischuria paralytica mani- 
fests itself by the difficulty of urination, excessive demands 
being made upon the abdominal muscles to aid in the ex- 
pulsion of the urine. The cause must, nevertheless, be 
accurately determined, and the possible existence of ureth- 
ral tumors especially should be considered. When drib- 
bling is present, the catheter is to be employed in order to 
exclude ischuria paradoxa and foreign bodies. 

Treatment of Cystitis. 

Recent gonorrheal urethritis and cystitis are treated as 
indicated in §12. 

In simple acute vesical catarrh (without fever) the blad- 
der is not to be disturbed ; the urine is to be rendered mild 
and unirritating ; above all, an abundance of tea and milk 
(add 25.0 of lime-water to J of a liter of milk if it is 
not well borne). Abstinence from all irritating foods, es- 
pecially alcohol. The diet should be bland, including egg- 
albumen, milk of almonds, bouillon, and rare meat. The 
bowels should be regulated by injections and mild laxa- 
tives. 

Instead of prescribing balsams, as was formerly the 
custom, urotropin (0.5, three times daily), potassium chlo- 
rate, or a solution of sodium salicylate (5 : 150) are given. 

The tenesmus is best controlled by rest in bed, warm 
fomentations, narcotics in vaginal or rectal suppositories 
(chloral, tincture of opium, morphin, extract of bella- 
donna), or chloral or opium by the mouth. The vesical 
mucous membrane itself absorbs nothing. Warm baths. 

In chronic cystitis due to infection irrigation of the 
bladder is to be added to the foregoing measures : physio- 



TREATMENT. 147 

logic JSaCl solution, 1-2 ^ boric acid, \ c f c salicylic acid, 
0.5-1 : 1000 nitrate of silver. To alleviate the irritation 
of the stronger solution, subsequent irrigations of 0.25^ 
cocain are employed. After solutions of nitrate of silver 
stronger than 6 : 1000, NaCl solution to precipitate the 
silver. If the mucous membrane is very sensitive, JSaCl 
or mucilaginous solutions (starch, oatmeal). 

The irrigations are carried out with a catheter, or with 
Kiistner's funnel (which I prefer to use, because of the 
easy formation of a fissure by the catheter) to which a 
tube and a glass funnel (Hegar^s) are attached. The 
latter should hold from \ to \ of a liter. The apparatus 
must be rigidly aseptic, and no air-bubbles are to enter the 
bladder. The funnel is to be filled several times in suc- 
cession. The temperature should be from 95° to 100° F. 
The pressure should not be too great, especially with a 
paralyzed detrusor urinse. The irrigations are made from 
one to four times daily ; if high fever is present, every 
two hours. 

The quickest results are obtained by permanent drain- 
age of the bladder, which is always to be employed if 
fissures and severe cystitis are present. As recommended 
by Fritsch, a rubber tube, 15 cm. long and 0.6 or 0.7 cm. 
in diameter, is introduced and is held in position by adhe- 
sive plaster (or Unna's zinc plaster) or by a suture through 
the nymphse. The tube should only be introduced far 
enough to allow the urine to flow out. The instrument 
must be changed every three days on account of the 
incrustation. 

Diphtheric membranes must be removed ; their pres- 
ence may be diagnosed from the numerous small incrusted 
shreds and from the bloody, decomposing urine. The 
urethra must be dilated by means of Simon's specula. 
The first three numbers are to be successively introduced, 
and the irrigation is to be carried out with j^o. 3. If 
hemorrhage occurs : Ferripyrin solution (1 : 5), solution 
of sesquichlorid of iron (1 : 800), or iodoform-ferripyrin- 



148 CYSTITIS. 

gauze tamponade through the speculum. The after-treat- 
ment consists of a bland diet and carbonated waters (such 
as Wildunger, Vichy) or mild infusions. 

Hypertrophy and contraction of the bladder are treated 
by regular catheterization and lukewarm irrigations, the 
amount being increased daily (to distend the bladder), 
cold baths, douches, and vaginal irrigations. 

For spasm of the bladder : Removal of the cause (for- 
eign bodies, etc.), bearing in mind fissures at the neck of 
the bladder or in the urethra ; if these are present, Fritsch's 
permanent catheter or dilatation of the urethra. Avoid all 
congestions : injections and mild cathartics ; forbid sexual 
intercourse ; hot foot-baths ; bland diet without alcohol. 
For the nervous excitability : Potassium bromid, mild 
hydrotherapy. During the attack : Chloral internally, by 
the vagina or rectum ; injections of morphin directly into 
the bladder, or irrigation with a cocain solution ; or the 
measures employed for tenesmus. 

In paralysis of the bladder the exercise of the will 
plays an important role as far as the sphincter is con- 
cerned — enuresis nocturna, for example (wake the patient 
several times during the night and have her empty her 
bladder) ; hydrotherapy ; roborants. 

Ischuria (detrusor paralysis) is treated by frequent 
catheterization, cool applications, and abdominal massage. 

If the muscularis is already paretic or paralytic (incon- 
tinentia paradoxa paralytica), electricity is to be employed. 
It is also of value in uncontrollable enuresis nocturna. 
One well-insulated pole is introduced into the bladder, 
which has been filled with water, and the other pole is 
applied to the symphysis, lumbar region, or perineum. 
Ergot is also employed. The treatment of the catarrh — 
catheterization and lukewarm irrigations — is usually of 
value in alleyiating this condition. 



CHAPTER II. 

DISTURBANCES OF NUTRITION AND CIRCULATION. 
(Exanthemata, Phlebectasia, Neuroses.) 

Since the female genitalia, and particularly the vulva, 
are unusually rich in nerves, glands, blood-vessels, and 
lymphatics in the shape of cavernous tissue, the affections 
of one set of structures easily spread to the others, and 
cause the most varied changes, which usually give rise to 
a typical symptom-complex : pruritus vulvae, vaginismus, 
dysmenorrhea, hysteria. 



?23- DISTURBANCES OF NUTRITION AND CIRCULATION. 
(a) Of the External Genitalia. 

By vulvitis pruriginosa we understand an inflammation 
of the external genitalia, associated with intense itching 
(pruritus). The parts are dry, fissured, and slate-gray in 
color. 

There are different varieties of vulvitis : simple redden- 
ing — dermatitis simplex ; if the corium and subcutaneous 
tissue are diffusely involved — phlegmone vulvae with 
abscess formation ; if partial — furunculosis ; if the sebace- 
ous glands are inflamed (small yellowish projections like 
acne) — folliculitis ; if an inflammation of the connective- 
tissue papillae (small red prominences) also exists — papil- 
lary vulvitis. There is a vulvitis diabetica. Bartholin- 
itis has been mentioned in §12. 

Cutaneous exanthemata (eczema, herpes, prurigo, mili- 
aria) rarely occur. 

Treatment. — Simple inflammation : Washings with warm soda 
solutions and the subsequent application of lead-water, solution of 

149 



1 50 NUTRITIONAL AXD CIBCULA TOE Y DISTURBANCES. 

aluminum acetate, zinc ointment. '20 % boric-vaselin, 10 c .'c carbolized 
oil. sitz-batlis, dusting-powders i bisniuth-talcmn ) . 

Severer inflammation : Soda solutions, then apply 5-10 -V solution of 
silver nitrate, and lead-water compresses. 

Abscesses: Incision. In furunculosis : Shave off the pubic hair; 
Unna's mercurial plaster in the beginning : later, warm sitz-baths. 
soap plaster, emollient cataplasms. 

Diabetic vulvitis: Constitutional treatment, meat diet, laxatives 
( sal carolinum ) . 

Folliculitis : Eemove the grease from the skin by means of solutions 
of potassium carbonate a piece the size of a walnut is dissolved in the 
wash-water I and immediate application of 5-10 c c solution of nitrate 
of silver. If pruritus is present, excision of the part, 5-V- menthol- 
alcohol, or menthol-lanolin. 

Pruritus: Washings with soda solution; application of 10 fr solution 
of nitrate of silver and subsequent 10 'V carbolic acid compresses: appli- 
cations of ice-water, compresses of 6'V menthol-alcohol, or J-l : 1000 cor- 
rosive sublimate, or salicylic acid: warm sitz-baths with J of a pound of 
wheat bran, oak-bark decoctions, or other astringents (alum, formalin, 
tannin |. Anodynes : cocain | expensive ! i. eucain B. chloroform, nior- 
phin. and belladonna act temporarily in cases having a neurasthenic 
basis and not rarely appearing after some acute exciting cause i fright i . 

(b) Of the Internal Genitalia. 

By vaginismus we understand a reflex spasmodic con- 
traction of the introitus vaginae from contact with the 
marked hyperesthetic. usually thickened and chronically 
inflamed, hymen, or carunculae myrtiformes. It is a 
symptom-complex similar to pruritus, but it also affects 
the motor elements. The two affections may coexist. Cen- 
tral or hysteric processes are also responsible, as is demon- 
strated by the fact that the lightest touch with a smooth 
instrument-handle produces the same result as the impetus 
cceundi or the introduction of a speculum. 

I had a patient in whom the introduction of an irriga- 
tion tube was easy and painless when carried out by her- 
self, but accompanied by intense pain when done by any 
one else. If her attention was engaged, a tampon could 
be introduced. The thought of a remarriage, with subse- 
quent coitus, also brought on an attack. 

There is one form of vaginismus, however, without 
pain, as is shown by the symptom of the " penis captivus." 
There are also neuroses of the vagina situated higher up — 



IXTEEXAL GEXITALLL 151 

painful area?, especially in the posterior vaginal vault and 
not associated with parametritic processes. 

Treatment. — Careful excision of the entire hymen, in- 
cluding the urethral orifice with its caruncles. In the 
ease mentioned the nymphae i folliculitis i were also re- 
moved, on account of pruritus. The patient married. 
conceived, had an easy delivery, and has now been a 
mother and wife for four years : in her first marriage. 
lasting for some years, she was an unhappy, and finally a 
divorced, woman. 

If the hypersensitiveness -till remains, the sphincter 
vaginae should be forcibly stretched. The actual anes- 
thesia of the part- is now demonstrated to the patient by 
palpation. Regular coitus and the speedy occurrence of 
impregnation remove the last vestiges of the trouble. 

In other cases conditions of pronounced nervous irrita- 
tion, and finally nervous depression, or even psychoses, 
occur. 

Masturbation is a frequent cause, hi such cases the 
time of the patient shouM be completely occupied by 
absorbing and fatiguing duties, and all irritations of the 
senses should be removed lectures, balls, theater, etc. ). 
Other causes are fissures, arising from a re-i-tent hymen, 
and impotentia cceundi on the parr of the male. See I 5. | 

A disturbance of nut agt I itis vetnlarum Paige . 

leads, as colpitis ulcerosa adhaesiva irregular areas of round-cell intil- 
d with desquamated epithelium . to adhesions, sears, and bridges 
of new tissue. 

Examples of vasomotor anomalies of innervation are 
furnished by phlebectasia of the vulva (Plate 51) and 
varicocele parovarialis i Plate 53 ) : the latter may give 
rise to intraperitoneal hematocele or hematoma of the 
broad li<^ament. 

The disturbance- of innervation of the arterial system 
are usually associated with similar affections of all the 
contractile elements of the genitalia and their supporting 
ligaments. This deficient "tonus" is a frequent occur- 



152 NUTRITIONAL AND CIRCULATORY DISTURBANCES. 



PLATE 51. 

Fig. 1. — Elephantiasis Vulvae Originating in the Labium 
Majus Dextrum and Polypoid Excrescences of the Mucous 
Membrane at the Urethral Orifice. The elephantiasis starts in 
the deeper connective tissue and consists of proliferated lymph-capil- 
laries (see Plate 29, Fig. 1), partly neuromatous (Czerny) and partly 
from stasis. The tumors may resemble external papillomata, but their 
excrescences are usually larger and flatter. (See Plate 24.) Some- 
times the tumors grow out from the entire vulva. Their growth is 
always slow and is characterized by great variations in size. 

Polyps of the urethral mucous membrane are seen at the external 
orifice or at the neck of the bladder. They consist of connective tissue, 
and rarely contain small retention cysts, arising from atresia of the 
excretory ducts of Skene's glands (in Fig. 20 the fine orifices of these 
glands are seen in the urethral wall). Other urethral tumors arise as 
varices, as vascular proliferations (angioma), as sarcoma and epithe- 
lioma. (Original water-color ; case in Munich Frauenklinik.) 

Fig. 2. — Phlebectasia of the Labia Majora, of the Clitoris, 
and of the Nymphse ; the Right Labium Majus Contains a 
Hematoma (Thrombus Vulvae) ; and Hemorrhoids. This con- 
dition is most frequently found in parturient or puerperal women, the 
varices being due to venous stasis ; the extravasation, to subcutaneous 
injuries of the vessels during delivery. Hematoma may also occur in 
nonpregnant women as a result of trauma. 

rence, and leads to descent and prolapse of the uterus, of 
the vaginal walls with the bladder and the rectum, and to 
retroversion and retroflexion of the uterus. It produces 
a chronic hyperemia of these organs, which becomes the 
noninfectious starting-point of an inflammation. 

These affections have been considered in §§ 7—11 and 
in §§ 13, 14, and 17. The foregoing common etiologic 
factor must be borne in mind, as it is of far-reaching im- 
portance. 

The partly uterine, partly ovarian symptom-complex of dysmenor- 
rhea is described in \ 4, under 8. 

The hysteric symptom-complex (see § 11, under Symptoms, and 
§ 17, under Diagnosis) represents a disease of the entire nervous sys- 



SY31PT0MS. —TEE A TMENT. 153 

tern, with a cerebral origin, and the evolution of certain phenomena, 
A predisposition either may preexist or may be induced by a too indul- 
gent education. This disease arises from marked sensual or emotional 
excitement, which individuals with healthy nerves bear without injury, 
or from a permanent feeling of self -dissatisfaction. 

In addition to congenital traits, a general predisposition is fur- 
nished by our city life, with its early manifold sensory impressions, its 
disproportionate mental activity, its luxuries and pleasures, and with 
its absence of actual invigorating labor, and of precise duties and cor- 
responding strengthening of the will. These pernicious factors must 
be excluded in youth ; amends must be made for them in later years. 

Diseases of the genitalia may bring on the disease, but they do not 
always produce hysteria, nor are they the only exciting causes. As 
such may be mentioned puerperal diseases, with their infectious irrita- 
tions and weakening hemorrhages ; chronic painful oophoritis and sal- 
pingitis; pelveoperitonitic adhesions; retro flexio uteri fixati; spas- 
modic angulation of a retroverted uterus; inflammations of the uterus; 
intramural myomata projecting from the os uteri; traction from polyps, 
etc. 

Symptoms. — 111 humor, hypersensitiveness, weakness of will. 

Epileptiform spasms and contractions, usually clonic, sometimes 
tonic, with perfect consciousness and reflex excitability (pupils) ; of 
the muscles of the extremities and trunk (Charcot's arch), with accel- 
erated respiration, and, according to the state of mind, paroxysms of 
shrieking, crying, laughing ; of the laryngeal and esophageal muscu- 
laris, spasm of the glottis (barking cough), spasm of the esophagus 
(globus hystericus). Singultus hystericus. 

Paralyses : of the extremities, unilateral and bilateral ; of the 
vocal cords, hysteric hoarseness and aphonia (as in a case with retro- 
flexion of the uterus at the Heidelberg clinic). 

General and partial hyperesthesias and anesthesias : Tussis uterina, 
emesis et vomitus, clavus hystericus, spinal irritation, " ovarie " (Char 
cot). 

Vasomotor and trophic symptoms : Palpitation, stenocardia, ner- 
vous dyspepsia, meteorismus ; anomalies of secretion of the skin 
(hyperidrosis, anhidrosis), of the kidneys (polyuria, oliguria or tem- 
porary anuria, ischuria) ; nervous diarrhea, etc. 

Diagnosis is made from the rapidly changing character of the 
symptoms. These do not form a clinical picture corresponding to 
pathologic changes in any definite organ. 

Treatment. — Prophylactic ( see Treatment of Vaginismus ) . — Psychic 
influence and education ; above all, never criticize the patient's view 
of her ailment, but demonstrate to her its general nervous character, 
and change the manner of living, the diet, etc. Eegulate the func- 
tions as indicated in § 4, under 7. Eestricted and bland diet or a more 
liberal one, as the case may be. Treatment of a genital disease, if 
present. 

Lukewarm baths to render the patient more hardy ; gradually lower 
the temperature from 88° to 72° F., fifteen minutest Electric baths. 

Symptomatic. — Potassium bromid (with heart disease, sodium 



154 NUTRITIONAL AND CIRCULATORY DISTURBANCES. 



PLATE 52. 
Edema of the Nymphae from a Moribund Patient with a 
Cardiac Lesion. (Original water-color from nature.) 

bromid) and monobromated camphor for the excitement, irritation, 
and palpitation ; phenacetin, lactophenin, heroin, sulphonal, trional, 
menthol, valerian. Chloroform, morphin, atropin, chloral, and ex- 
tract of belladonna (by the mouth, by the rectum, or hypodermically ) 
are all used for the neuralgias and as sedatives or hypnotics. They 
usually do more harm than good. For the paralyses, faradization or 
massage ; for the sj)asins and convulsions, cold water in every form 
known to hydrotherapy. 

Charcot's so-called " Ovarie " has been mentioned in § 17, under 
Diagnosis. In the great majority of cases it has nothing to do with 
the ovaries or even with the adjacent nerve plexuses. It is generally 
either a neuralgia of the nerves passing through the abdominal recti 
muscles toward the hypogastrium, or neuralgia of the posterior vaginal 
vault, of the pouch of Douglas, and of the contiguous portion of the 
rectum. The latter cases are usually associated with vasomotor and 
motor disturbances of innervation of the parts. (See the author's 
paper in the u Mon. f. Geb.," January, 1898.) 

Coccygodynia is a local hyperesthesia of the plexus coccygeus. 

Treatment. — Hydrotherapy, or, in extreme cases, extirpation of 
the os coccygeus. 

Sometimes confusion may arise from a pain, which is experienced 
in the coccygeo-anal region, but the location of which may be shown 
to be considerably higher — in the posterior vaginal fornix or about the 
pouch of Douglas; not rarely varicoceles in the broad ligament and 
hemorrhoids high up in the rectum may be demonstrated. In the 
puerperium, immediately after delivery, and sometimes even occasion- 
ally during pregnancy, an analogous pain is experienced, which is 
falsely ascribed to the coccyx, to pressure on its plexus, to periosteitis, 
to luxations, etc. Careful palpation from the rectum and externally 
excludes these conditions. 








1 



\ 







GROUP IV. 
INJURIES AND THEIR CONSEQUENCES. 



CHAPTER I. 

DEFECTS WITH CICATRICIAL CHANGES. 

All varieties of genital lesions arise by far most fre- 
quently during delivery. The effect they produce is 
dependent upon their location. Cicatrices in the vulva 
rarely cause atresia ; on the contrary, they produce a gap- 
ing. Lacerations of the external os may heal with ectro- 
pion ; nevertheless, here, as in the vagina and cervix, 
stenosis and atresias are more likely to occur. 



i 24. INJURIES OF THE VULVA (INCLUDING FISSURES) 
AND PERINEAL DEFECTS, INCONTINENTIA VULV/E. 

Definition. — The solutions of continuity, which are 
now to be considered, have the character of incised, of 
lacerated, and of lacerated and contused wounds. A 
natural division, based upon the depth of the injury, is as 
follows : 

1. Fissures: Slight linear solutions of continuity of 
the surface, occurring at the frenulum perinsei and pro- 
ductive of specific results when involving the hymen, the 
neck of the bladder, or the urethra. (See §§22 and 23.) 

2. Lacerations of the perineum of the first degree : 
Tears of the frenulum perinsei and of the mucous mem- 
brane of the vestibule. 

155 



156 VULVAE AND PERINEAL INJURIES. 



PLATE 53. 
Phlebectasia with Phleboliths of the Ligmenta Lata Cor= 
responding to the Ovarian Vessels and the Pampiniform 
Plexus. The venous stasis in the remaining portions of the broad liga- 
ments is also apparent. (Original water-color from an autopsy at the 
Heidelberg Path. Inst. ) 



3. Tears of the mucosa of the fossa navicularis, the 
skin surface of the perineum being intact, but under- 
mined. This important and easily overlooked variety is 
not rarely produced by the posterior shoulder. 

4. Lacerations of the perineum of the second degree : 
Tears extending to the sphincter ani. 

5. Perforations of the perineum (rare) : Canal-like 
lacerations, which pass from the vagina through the 
middle of the perineum, sometimes involving the anus, 
the anterior portion of the frsenulum perinsei being left 
intact. 

6. Lacerations of the perineum of the third degree, or 
complete lacerations : the tear extends into the rectum. 

"While all these tears are brought about, almost without 
exception, by incidents of the sexual life (cohabitation, 
delivery, and the puerperium — urethral fissures from cathe- 
terization), the parts of the vulva are also exposed to other 
traumatisms. These are followed by serious results, espe- 
cially if occurring during pregnancy, when the parts are 
very vascular. The region of the clitoris is the most 
exposed to wounds, which are usually caused by falling 
astride of some object. It is also the most dangerous 
region, as patients have bled to death in a short time from 
hemorrhage from the corpus cavernosum. 

Hemorrhages and injuries of this character must be 
treated immediately by suture. 

Lacerations and perforations of the nymphse are not 
productive of further consequences. 



CO 



^v 




SY3IPT0MS. —SEQ UELS. 157 

Symptoms and Consequences of Perineal Lacera- 
tions. — If primary union is not obtained by immediate 
suture after delivery, these wounds heal by granulation, the 
lower portions of the labia being drawn apart and dis- 
torted. 

/ Fissures cause only a burning, and may induce infectious 
/ulceration ; they may nevertheless be produced in a peri- 
neal cicatrix as rhagades (after coitus, difficult defecation). 

In perineal lacerations of the first degree (Plate 54, 
Fig. 3) the tuberculum vaginae loses the covering and sup- 
port of the frenulum perinsei. This portion of the anterior 
vaginal wall prolapses ; the urethral orifice gapes ; x there 
is a predisposition to urethritis and vesical catarrh. 

In perineal lacerations of the second degree the posterior 
vaginal wall prolapses from above the scar (see Plate 27) ; 
and if the entire pelvic suspensory apparatus, including 
the pelvic fascia and the levatores ani muscles, has lost its 
" tonus/' all those downward displacements described in 
§ § 7 and 8 and their appurtenant plates may occur. In 
addition, uterine and vaginal catarrh, cystocele, and recto- 
cele, and their sequels, are produced. 

In perineal lacerations of the third degree — the complete 
variety (Plates 7, 1 ; 54, 2 and 4 ; Fig. 26) — fecal inconti- 
nence is present, because the voluntary external sphincter 
muscle is torn. In extreme cases the internal sphincter is 
also involved. 

As is shown in the sagittal section of the perineum (Plate 54, 
Fig. 1), the transversely striated external sphincter forms a rounded 
body about the anal pouch (see the corresponding outline of the shad- 
ing), while the internal sphincter passes vertically upward from it as 
an elongated mass of fibers. Both sphincters are absent in figures 2 
and 4; in figure 3 they are both present. The whole perineum may 
be destroyed, and yet a portion of the external sphincter may remain 
intact. 



1 In Heidelberg I saw such a case in a peasant's wife. The impetus 
coeundi had been directed against the prolapsed tuberculum vaginae 
and, in this manner, had so dilated the urethra that the finger could be 
readily introduced. (Plate 19, 2.) 



158 VULVAE AND PERINEAL INJURIES. 

PLATE 54. 

Fig. 1. — The normal perineum is a physiologic support for the vagi- 
nal walls, and indirectly for the uterus. The intact perineum forms 
the lowest part of the vulva, being at a lower level than the end of 
the anterior vaginal wall. It resembles a triangle placed beneath the 
vaginal ostium and supporting the tuberculum vaginae. It also sup- 
ports the entire posterior vaginal wall, which, in its turn, holds up the 
upper half of the anterior one. The normal cervix looks backward, 
resting against the posterior vaginal fornix, and the corpus uteri de- 
rives its support from the anterior vaginal wall. 

Fig. 2. — Perineal Laceration of the Third Degree (into the 
Rectum). Inversion of the anterior vaginal wall with beginning 
cystocele ; descensus uteri from flattening of the anterior vaginal vault. 

Fig. 3. — Perineal Laceration of the Second Degree. The 
loss of support of the anterior vaginal wall is clearly shown. 

Fig. 4. — Perineal Laceration of the Third Degree. Inver- 
sion and prolapse of the posterior vaginal wall ; beginning retroversion 
of the uterus. 

There are cases, however, in which solid, and even 
liquid, stools can be voluntarily controlled. This is due 
either to an intact portion of the external sphincter, the 
tear not extending 1| cm. into the rectum, or to the fact 
that the lowest portion of the rectum has undergone cica- 
tricial contraction. Such cases are not easy to diagnose, 
because these rectal scars become pigmented and covered 
with epidermoid tissue. 

The scars may be the seat of neuralgias or pruritus. If 
fissures form, burning and tenesmus are present. The 
continual moisture of the prolapsed vaginal walls, with or 
without discharge or intertrigo, is a constant source of an- 
noyance ; there arises a dragging sensation, as if the inter- 
nal organs would fall out. The deficient closure of the 
vulva, which increases with the senile atrophy of fatty 
tissues, allows air to enter the vagina ; any increase of the 
abdominal tension will force this air out in an audible 
manner — garrulitas vulvae. 



TREATMENT. 159 

Treatment. — These serious symptoms are best treated 
by plastic operations, as mentioned in § 8. The success 
of the operation depends partly upon the preparation of 
the patient : disinfection of the vagina and cervix by 
sponging and irrigation, emptying of the bladder, and 
especially of the rectum (two or three days before the 
operation). Narcosis. Cotton tampon in the rectum. 

The operation may be performed soon after the comple- 
tion of the puerperium. Not only must the cutaneous 
bridge between the lower ends of the labia be restored, 
but the new septum, with its anterior edge (corresponding 
to the frenulum), must also cover the tuberculum vagina? 
and support the anterior vaginal wall. 

This new perineal septum must, further, have the same 
size and shape (triangular in sagittal section) as the normal 
perineal body, so that a new fossa navicularis will be 
formed. 

The outline of the denudation will vary according to the 
nature of the defect ; if the vagina is injured and deeper, 
it is hat-shaped (Hildebrandt and Freund) ; if the chief 
lacerations are in the lateral portions of the vagina, it is 
shaped like the wings of a butterfly (Simon and Hegar). In 
the latter case the area is denuded in that manner so as to 
form a perineal body resembling the original one. Fritsch 
pursues the same course, excising the scars in the vagina, 
with their lateral extensions, and inserting stitches toward 
the vagina, toward the perineum, and toward the rectum. 

Hildebrandt, Freund, and Martin cut one or two or more 
triangular flaps from the vagina : i. e., either avoid or 
remove the columna rugarum posterior. 

Bischoff, v. AVinckel, and Kiistner (episioplasty) procure 
a median vaginal flap or two lateral vulvar flaps of corre- 
sponding shape to the outline of the scar, the principal 
portions of which are rarely in the middle line. This is 
known as flap-perineorrhaphy. 

Simpson, Lawson Tait, Sanger, Zweifel, and v. Winckel 
perform perineoplasty in as conservative a manner as pos- 



160 VAGINAL AND CERVICAL LACERATIONS. 

sible : i. e., without the removal of tissue. This method has 
been improperly denned as flap-perineorrhaphy. A trans- 
verse incision is made in the rectovaginal septum, and its 
edges are drawn upward and downward by means of 
tenacula. The original transverse wound is now closed by 
a vertical row of sutures (deep and superficial), drawing 
the tissues together in the median line. [In America the 
importance of repairing ruptures of the pelvic fascia and 
of the levatores ani muscles is so thoroughly appreciated 
that Emmet's plan of operating for so-called perineal 
lacerations has largely superseded all others. — Ed.] 

The complete perineal lacerations (third degree) are 
operated upon according to the same principles ; here the 
edges of the rectal tear must also be freshened and must 
be united by sutures. 

After=treatment — It is best to leave the wound un- 
covered ; it should be frequently irrigated, and the most 
rigid cleanliness should be maintained. The knees are to 
be bandaged together. The sutures are allowed to remain 
as long as possible (from ten to twenty days) ; the best 
materials are silver wire and silkworm-gut. 

On the third day, or soon thereafter, the bowels should 
be moved by castor oil in capsules ; high injections may be 
used, if necessary. In most cases opium is unnecessary 
for the production of an artificial coprostasis if the intes- 
tinal tract has been previously thoroughly evacuated and 
the patient is kept upon a nutritious liquid diet. If indi- 
vidual sutures cut through, they are to be removed. 
Should a rectovaginal fistula occur, the entire septum is to 
be divided, all granulation tissue removed, and the wound 
surfaces united as before. 

The patient is to be kept in bed for two or three weeks. 

1 25. LACERATIONS OF THE VAGINA AND CERVIX. 

(a) Simple injuries of the vagina (t. e., without opening neigh- 
boring organs) occur most frequently during delivery. They are also 
the result of accidental trauma or of unskilled or rough manipulations, 



CERVICAL TEARS. 161 

such as forced coitus, especially in elderly women or where the dispro- 
portion between the size of the genitals is great ; rape ; clumsy opera- 
tive procedures or examinations ; the introduction of specula that are 
too large ; attempts at abortion ; and cauterizations. 

Symptoms. — Often union per primam ; sometimes severe hemor- 
rhages or septic infection. The author observed, two hours after a tear 
of the fornix with most profuse hemorrhage (illegitimate coitus of an 
English woman forty-nine years of age, who had had a child twelve 
years before, and who suffered from vaginismus), a temperature of 
101.3° F., a pulse of 120, and an acute urticaria covering the entire 
body, which lasted twelve hours. 

Treatment. — Disinfection, removal of necrotic shreds, ligation or 
suture of vessels, coaptation of fresh wounds, tamponade with ferri- 
pyrin, alum-iron chlorid, iodoform, nosophen, or itrol gauze. Old 
vaginal scars producing stenosis or atresia are to be excised, stretched 
(manually or by tamponade), or treated by plastic operations. This 
will make the treatment tedious, and if conception has already occurred, 
complicated methods of delivery may be necessary. 

(b) Tears of the cervix lead to commissural or to star- 
shaped defects (Plate 55), to scars of the os uteri, and, 
secondarily, to ectropion. (§ 13 and Plate 56.) If they 
extend into the vaginal vault and the paracervical connec- 
tive tissue, they produce torsions and fixed displacements 
of the neck of the uterus. (See § 11 and Plate 55.) 

These lacerations, instead of undergoing simple cicatriza- 
tion, many persist for a considerable time as yellowish- 
gray, fissured ulcers with reddened edges. Both processes 
occur most frequently at the commissures of the os uteri, 
because these portions of the tissues heal poorly. The 
ulcers are immediately followed (even in the puerperium, 
see § 15) by endometritis, metritis and parametritis, and 
secondary ectropion ; the scars cause direct ectropion and 
a secondary uterine catarrh. 

The distortions produced by the scar tissue cause radiat- 
ing pains in the lower extremities and nervous reflexes 
similar to the epileptic and epileptiform attacks associated 
with scars elsewhere. 

Treatment. — Emmet first directed attention to these 

fissured ulcers and their consequences, and recommended 

their treatment by the following procedure : The lips of 

the ectropion are fixed with tenacula ; the commissural scar 

11 



162 TRAUMATIC STENOSES AND ATRESIAS. 



PLATE 55. 
Fig. 1. — Torsion of the Cervix Produced by Scar Tissue. It 

extends posteriorly from the commissure of the os uteri into the base 
of the left broad ligament. 

j? IG> 2. — Star=shaped laceration of the external os, resulting 
from difficult labor with a rigid cervix, or from an operative delivery 
before the external os is sufficiently dilated. Tears occur in the lips 
of the os uteri just as frequently as in their lateral commissures ; 
while the former usually heal well, the cicatrization of the latter is 
affected by the poorer vascular supply of the sides of the cervix, and 
results in a greater degree of contraction. The lips of the os gape and 
the cervical mucosa gradually protrudes (ectropion). 

tissue is excised, going into the vaginal vault if neces- 
sary (not too deeply, however, on account of the large 
vessels), and the surfaces of the wound are united. 
The Martin-Skutsch modification is described on page 89, 
and the excision of the proliferated mucous membrane in 
§ 14. Sanger designed a hysterotrachelorrhaphy. By 
these methods the normal shape and size of the cervix are 
restored. 



§ 26. TRAUMATIC STENOSES AND ATRESIAS OF THE 
VULVA, OF THE VAGINA, AND OF THE UTERUS. 

The congenital stenoses and atresias are described on 
pages 22 to 29, 33, and 36 to 38. 

PLATE 56. 
Fig. 1.— Laceration of the Left Commissure of the Os Uteri, 
with Marked Ectropion and Ovules of Naboth on the Project= 
ing Hypertrophied Cervical Mucosa. (See Plates 28; 29, 4; 30; 

90, 3.) 

Fig. 2. — Old Ectropion and Congestion of the Cervix. The 

mucosa becomes wrinkled from the minute cicatricial contractions of 
the newly formed connective-tissue fibers (endometritis interstitialis 
chronica, see Plate 31, Fig. 2). 






/ 










*■• 



ETIOLOGY.— SYMPTOMS, 1 63 

Anatomy and Etiology. — Xarrowings, and even cica- 
tricial adhesions, are brought about by chronic inflamma- 
tory processes, circumscribing ulcers with marked con- 
traction, too severe cauterizations, and injuries. They are 
seen in advanced life and in connection with acute infec- 
tious diseases. 

The ulcerated labia become adherent ; the urethral 
orifice even may be temporarily occluded. There is a 
retention of blood and of the secretions of the entire 
genital canal. 

Actual obliteration occurs in the vagina, chiefly from 
cauterization and in advanced age. 

The external os is the most frequent location for these 
agglutinations. It is either contracted to a small, round, 
cicatricial opening, or subdivided by a bridge of tissue, or 
retracted by scars into a funnel of mucous membrane. The 
stenosis may be short and circumscribed or long and tubu- 
lar, leading, correspondingly, to a membranous or to a cord- 
like atresia. Atresias of the internal os from too severe 
cauterizations are rarer ; those of the ostium tubse are still 
more infrequent. For the anatomic changes see §1 (6). 

Symptoms and Diagnosis. — Stenosis results in dys- 
menorrhea and sterility (see § 3), with primary or second- 
ary inflammation. The stasis produces either tension and 
nausea or colic. 

In atresias the more pronounced phenomena first be- 
come apparent at puberty (see § 1, 6-8 (c?)). The diagnosis 
is made by examination with speculum and sound ; in 
hematometra, hydrometra, pyometra, and lochiometra bi- 
manual examination demonstrates a tense elastic tumor 
occupying the position of the uterus. In time, perimetritic 
changes take place. 

Treatment. — To the operative enlargements by forced 
dilatation, and by incision of the commissures of the os 
uteri, described in § 3 (3, 4), may be added a variation of 
v. AVinckel's, which is employed if thickening of the 
cervix is present. If the cervix is thickened and elon- 



164 TRAUMATIC STENOSES AND ATRESIAS. 

gated, it is removed by the elastic ligature ; if it is, how- 
ever, only thickened and the os narrowed, the operation 
of Sims (p. 37) is performed, and then small wedges are 
cut out of the four wound surfaces produced by the com- 
missural incisions. The wedge-shaped defects are sutured 
as in Sims' method. Lastly, excision of the cervix, ac- 
cording to Kaltenbach, may be performed. 

The acquired atresia with hematometra is naturally 
much more dangerous (from septicemia) than the con- 
genital form. A free incision must consequently be made 
as early as possible, the uterine cavity carefully washed 
out with a 2 ft carbolic solution, and drained by iodoform 
gauze or by a tube. (See p. 29.) 

Hematosalpinx and hematometra with a uterus bicornis 
are to be removed by celiotomy. 

Acquired atresia of the vulva is treated by dividing the 
adhesions and packing with iodoform gauze, or the raw 
surfaces may be separately sutured. 



CHAPTER II. 



FISTULAS. 



Fistulas are most frequently the result of trauma 
during delivery. They may be the immediate result of 
lacerations, or they may arise secondarily from the slough- 
ing of contused parts. Other fistulas are due to pessaries 
(especially the winged pessary of Zwanck), operations, 
foreign bodies, accidental traumatism, and perforating 
ulcerative processes — such as occur in malignant tumors 
(see Plates 85, 86, 88, 89), diphtheric inflammations of 
the puerperium, syphilis, vesical calculi, and to the perfor- 
ation of a perimetritic or parametritic abscess, of a 
hematocele, or of an extra-uterine gestation sac. 

Several fistulas may exist in the same case, as is shown 
in figures 40, 42, 43, and 48 to 51. 



\ 27. CLASSIFICATION OF FISTULAS. 

For a more exact study of the more recent works see the classic 
dissertation of Fritsch in Vert's " Handbook." 

A. Fistulas of the Urinary Organs. 

Anatomy. — According to the location of their orifices, these fis- 
tnlas may be divided as follows : 

1. Urethrovaginal fistulas (Fig. 37), opening below the tnbercnlnm 
vaginae. 

2. Vesicovaginal fistulas (Fig. 39), the most frequent. Every portion of 
the posterior x bladder- wall, as high up as the vertex, may be in- 
volved ; they are more frequent as the vaginal vault is approached. 
If the fistula extends to the edge of the external os, it is designated 
as a : 

3. Superficial vesicocervicovaginal fistula. (Fig. 38.) This form is 
of especial importance, because its cicatricial dragging upon the lips 

1 The original reads " anterior." — Tbaxslatob. 
165 



166 



FISTULAS. 



of the os uteri gives it a particular influence upon the uterocervical 
canal. If the os uteri is also torn, we have a : 

4. Beep vesicocervieovaginal fistula with destruction of the anterior 
lip. (Fig. 40. ) Both 3 and 4 are small, and are found in the median 
line, because they arise in contracted pelves, from contusion against 
the symphysis. 





Fig. 37. — Urethrovaginal fistula. Fig. 



38. — Superficial vesicocer- 
vieovaginal fistula. 



5. Vesicocervical fistulas. (Fig. 41.) They represent narrow canals 
which, from the peculiar anatomic relations of the cervix and vaginal 
vault, may be combined with vesicovaginal fistulas, since the vesical 
end may fork (Fig. 42) or two fistulas may coexist. 

The tear may be laterally placed, involving the vesical orifice of 
the ureter. If the other opening is in the vaginal wall, we have a: 





39. — Vesicovaginal fistula. 



Fig. 40. — Deep vesicoeervieo- 
vaginal fistula with a defect of the 
anterior lip of the os uteri. 



6. Vesico-ureterovaginal fistula. (Fig. 43.) Such a fistula will be 
found laterally along the course of the ureter or posteriorly in the 
vaginal vault. 

Simple ureteral fistulas arise when the injuries are situated high 
up; even then they may pass to the vaginal vault as: 

7. Ureterovaginal fistulas. (Fig. 44.) As in all ureteral fistulas, 
the orifice is so minute that its recognition is difficult. Its position is 



URINARY FISTULAS. 



167 



the same as in 6; they frequently empty, as does the urethra, upon a 
reddened prominence. 

8. Ureterocervical fistulas. (Fig. 45. ) 

There are also uretero-intestinal and uretero-abdominal fistulas. 

9. Vest co-abdominal fistulas. (Fig. 46. ) These urinary fistulas are 
peculiar in their origin. They include different degrees and locations 





Fig. 41. — Vesicocervical fistula. 



Fig. 4*2. — Vesicocervi co vaginal 
fistula with eolpocleisis. 



of the defect. Their occurrence is very rare; they are usually of a 
congenital nature, rarely the result of perforation into an inflamed 
adherent bladder. 

We designate as fissures: 





Fig. 43. 



-Vesi co-u ret ero vaginal 
fistula. 



Fig. 44. — Ureterovaginal fis- 
tula — bilateral (inflammatory 
adhesions). Bl, bladder. 



{a) The fissura vesicae inferior — a cleft beneath the united sym- 
physis, often combined with a fissured clitoris. 

(6) The fissura vesicse superior — a cleft above the normal symphysis. 

(c) The fistula vesico-umbiUcalis : i. e., the persistent urachus. This 
is an actual fistulous tract. 

(d) Eversio (exstrophia, ectopia) vesicse — clefts of the bladder, with 



168 



FISTULAS. 



or without a fissured symphysis. (See $ 1.) These are extreme con- 
genital defects. 

10. lleovesical or ileo-ureterovesical fistulas. (Fig. 51.) Of the com- 
munications between the bladder and intestine due to trauma and 
ulcerative perforations, that with the small intestine is the more fre- 





Fig. 45. — Right-sided uretero- Fig. 46. — Vesi co-abdominal fistula 
cervical fistula : R, rectum ; Bl, (persistent urachus). 

bladder. 

quent. There are also fistulas connecting the bladder with the 
stomach. 

11. Rectovesical or recto-ureterovesieal fistulas (Fig. 50) arise from 
perforating pelvic abscesses. 





Fig. 47.— Central perforation of Fig. 48. — Ileovaginal fistula. 

the perineum. Rectovaginal fistula (most fre- 

quent variety). 



B. Intestinal Fistulas. 

1. Rectovaginal fistulas (Figs. 48 and 49), or rectovestibular fistulas 
(when outside of the hymen). 

2. Ileovaginal fistulas (Fig. 48) : an opening in the small intestine 



INTESTINAL FISTULAS. 



169 



empties (usually) iuto the vaginal vault in such a manner that the 
greater portion of the feces passes on through the intestinal canal. If 
the upper end of the ruptured bowel is united with the vagina through- 
out, complete defecation occurs through this canal. This communica- 
tion is designated as an : 




Fig. 49. — Ileovaginal preter- 
natural anus. Kectovagiual fis- 
tula. 




Fig. 50. — Vesico-ureterorectal 
fistula. Siuistropositio uteri. i?, 
Rectum. 



3. Ileovaginal preternatural anus. (Fig. 49.) Both varieties are very 
rare, occurring in both the anterior and posterior peritoneal pockets. 

Fistulas vary greatly in shape and size. At first they 
are usually wide ; later, they undergo cicatricial contrac- 
tion ; they may pursue a 
direct or a tortuous course. 
Vesicovaginal and recto- 
vaginal fistulas are the 
largest. The length is de- 
pendent upon the mode of 
origin ; they may be long 
and multiple, for example, 
when they follow the per- 
foration of an abscess into 
two hollow viscera. If the 
tissue has undergone necro- 
sis from contusion, the surrounding scar tissue is quite 
extensive ; a clean-cut fistula is surrounded by much 
healthier walls. In the beginning every fistula is char- 
acterized by secretion, and forms granulations. 




Fig. 51 . — Ileo-ureterovesical 
fistula D, Ileum in the vesico- 
uterine pouch. 



170 FISTULAS. 

The concomitant injuries may be so great that it is im- 
possible to find the uterus in the cicatricial mass. 

If the urine is constantly emptied through the fistulous 
tract, the normal passage becomes contracted — or even 
obliterated, in the case of the ureters and the urethra. In 
the larger vesicovaginal fistulas the bladder-wall be- 
comes invaginated into the vaginal lumen, giving rise 
to slight catarrhal inflammations and polypoid prolifera- 
tions, which may lead to dangerous inflammations of 
the kidneys. Further results are pericystic irritations 
and adhesions. 

The genital mucous membranes and the vulva become 
inflamed and incrusted from the constant dribbling of the 
decomposing urine. 

Inflammations of the rectum develop in a similar man- 
ner. In perforating ulcerations the fistula pursues an 
oblique course, the larger primary orifice being the higher. 
(Fig. 49.) 

Symptoms. — Incontinence of urine, varying according 
to the nature of the fistula and the position of the patient ; 
if the vulva is swollen, the urine may be retained in the 
vagina in the recumbent posture. This incontinence does 
not come on immediately after the injury, but follows the 
sloughing of the tissues from pressure necrosis. 

1. In urethrovaginal fistulas the sphincter, and conse- 
quently the voluntary closure, may be maintained, but the 
direction taken by the stream of urine is different. 

2. In vesicovaginal fistulas (with large orifices not 
occluded by cicatricial membranes or temporarily blocked 
by calculi, etc.) permanent incontinence is present. 

3. In vesicovaginal fistulas emptying into the fornix 
and in vesico-uterine fistulas the patient, when erect, can 
hold her urine until the lower portion of the bladder has 
become filled ; the uterus, in addition, may act as a lever 
or as a valve — the body drops forward, distorting and dis- 
placing the fistulous tract and the cervix may directly 
occlude it (in vesico-uretero-uterine or vesico-ureterovag- 



SYMPTOMS. 171 

inal fistulas). In the recumbent posture the urine trickles 
directly into the vagina. 

4. In fistulas of the ureter the emptying of the bladder 
is voluntary, as only a small amount of urine can escape 
through the narrow canal ; the lesion may be unilateral, 
only affecting the urine from one kidney. Some of the 
urine passes through the vagina during urination. 

5. In the smaller rectovaginal fistulas only flatus and 
liquid stools escape involuntarily ; in the larger ones there 
is incontinence of well-formed fecal masses. 

The maceration of the tissues by the urine gives rise to 
a penetrating odor and to catarrhs of the genitalia with 
ulcerations of the vulva; sleeplessness and loss of appe- 
tite occur ; the patient feels that her presence is annoying ; 
she isolates herself, becomes unable to work, and falls into 
a melancholic state. The same is true of fecal fistulas. 
The general condition passes from bad to worse, and 
the patient finally succumbs after years of discomfort. 

Diagnosis. — Fistulas situated in the anterior vaginal 
wall are the easiest to recognize. If they are as large as 
the finger-tip, simple digital examination may suffice. A 
sound or catheter may be passed through them from the 
bladder. 

Small fistulas — especially lateral ones or those empty- 
ing into the cervical canal — may be demonstrated by the 
injection of colored liquids (milk, solution of potassium 
permanganate) into the bladder and careful inspection of 
the suspected location through the speculum. The suspi- 
cious area is fixed by tenacula and the course of the canal 
is determined by fine sounds. In vesico-uterine fistulas 
the external os must be everted, dilated, or incised ; ste- 
noses must also be previously removed. 

If urine, but not the colored liquid, flows through the 
genitalia, we have to do with a fistula of the ureter. The 
uretero-uterine fistula is differentiated from the corre- 
sponding vaginal one by the vagina remaining dry after 
firm tamponade of the os uteri. The exit of the fistula 



172 FISTULAS. 

may be more definitely fixed by giving the patient methy- 
lene-blue (0.1) several hours before the examination, and 
thus coloring the urine. 

If doubt exists, the cystoscope may be employed or the 
urethra may be dilated with Simon's specula and the in- 
terior of the bladder palpated. This procedure also gives 
a clue to the existence of other varieties of vesical fistula 
(ileovesical, etc.). As a last resort, Trendelenburg per- 
forms a suprapubic cystotomy. 

In intestinal fistulas conclusions may be drawn from the 
nature of the fecal mass (ileum or colon-rectum). 

Treatment. — Operative closure of the fistula is made 
possible by modern advanced technic. Minute exactness 
is of even more importance than in colporrhaphy or perin- 
eoplasty. 

If stenosis of the urethra exists, it must be dilated 
before the fistula is closed. 

Cervical fistulas are operated upon after incising the lips 
of the os uteri. Ureteral fistulas are closed by means of oval 
flaps, which are sutured over a catheter introduced into the 
ureter (after an artificial vaginal fistula has been made — 
colpocystotomy, to allow of the introduction of the ureteral 
catheter) (Simon, Schede). The free ureteral end with its 
surrounding mucous membrane may be excised and im- 
planted into the bladder (Mackenrodt). If the operation 
is not possible through the vagina, a lateral abdominal sec- 
tion may be made, the peritoneum stripped up, the ureter 
dissected out along the linea terminalis and sutured into 
the bladder. The intraperitoneal operation is hazardous. 

If the typical operations fail to close the fistula, trans- 
verse obliteration of the vagina (colpocleisis, Simon) may 
be performed : i. e., the vaginal cavity is converted into a 
reservoir connected with the bladder, an artificial atresia 
being produced in its upper portion ; the lips of the os 
uteri may be freshened and united by suture (hysterocleisis). 
Vesicocervicovaginal fistulas may be closed in an analogous 
way, either by the lips of the os or by the body of the 



TREATMENT. 173 

extremely anteflexecl uterus. The condition brought about 
by colpocleisis is not very promising ; in some cases 
catarrhs, incrustations, and the like demand the removal 
of the obliteration. In such a case, nevertheless, the 
fistula was subsequently permanently closed by v. Winckel. 

After=treatment. — Antiseptic irrigation of the bladder 
immediately after the operation (test the completeness of 
the closure by milk or potassium permanganate). Later, 
it is necessary to catheterize only if voluntary urination is 
impossible. A catheter may be introduced and per- 
manently retained. Rest in bed for several days only. 
Silk sutures are removed on the fifth, silkworm-gut on the 
eighth, day. Vaginal irrigation only when a fetid dis- 
charge exists. If subsequent operations are necessary, 
they may be performed four weeks later. 

Rectovaginal fistulas are in most cases also to be operated 
upon either by circumscribing them by an oval incision, 
and uniting their edges by deep sutures, or by the use of 
vaginal flaps. Very small fistulas, or those combined with 
anal defects or following perineoplasty, are closed by means 
of division of the entire rectovaginal septum. Laxatives 
are previously given for several days ; both organs are 
thoroughly irrigated with antiseptic solutions. During the 
operation the upper margin of the fistula is drawn down 
by tenacula and the upper portion of the rectum is plugged 
with cotton. Subsequent liquid diet and mild cathartics 
on the third or fifth day are indicated. 

In an ileovaginal fistula the spur must first be destroyed 
by clamp-forceps, so that the fecal contents may pursue 
their normal course after the plastic closure of the fistulous 
tract. 

Cauterizations by means of fuming nitric or sulphuric 
acids, chlorid of zinc, Vienna paste, caustic potash, nitrate 
of silver, the hot iron, or zestocausis are uncertain ; they 
are slow in producing results, and as they render the edges 
of the fistula hard and nonvascular, the tissues are in an 
unfavorable condition for later operations. They are of 



174 FISTULAS. 



PLATE 57. 
Rectouterine Hematocele in Combination with an Extra= 
uterine Gestation Sac. In this mass I found an embryo of three 
weeks (above and to the left, near to the tube). (Original water-color 
from a specimen removed at the Heidelberg Frauenklinik. ) 

value in long, narrow fistulas with healthy granulations. 
Their use may be combined with the retained catheter of 
Fritsch. (See § 22.) 



Tab 57. 



S 







■ 






hold, Miincheti 



CHAPTER III. 

TRAUMATIC EFFUSIONS OF BLOOD. 

Traumatic effusions of blood may take place in the 
connective tissue surrounding the genitalia (hematoma) or 
into the peritoneal cavity (intraperitoneal hematocele). 

§28. HEMATOMA: (a) VULVAR; (b) EXTRAPERITONEAL 

HEMATOMA (RETROUTERINE, PERIUTERINE, 

OR ANTE=UTERINE). 

(a) Vulvar hematoma (see Plate 51, Fig. 1) arises 
suddenly, with irritation and pain, and forms a tense, 
elastic, fluctuating, bluish tumor in the labia. 

Treatment. — Ice-bag and compression; if the skin 
shows a tendency to break down, incise and pack with 
iodoform gauze ; recovery is slow. 

(b) Extraperitoneal, retro-uterine, peri-uterine, 
and ante-uterine hematoma (Plate 58, Fig. 3), espe- 
cially in the broad ligament and gravitating alongside of 
the vagina to the pelvic floor. These come on after 
trauma (such as a fall), with signs of concealed hemor- 
rhage, violent pelvic pain, and disturbances of the blad- 
der and rectum. Fever and peritoneal irritation are 
absent, unless the broad ligament ruptures and an intra- 
peritoneal hematocele of Douglas 3 pouch is secondarily 
formed. 

Bimanual palpation shows the pouch of Douglas to be 
empty ; the posterior vaginal vault is pushed down, or a 
tense elastic tumor may be felt at the side of the uterus. 

The internal ligaments may be so slightly lacerated 
that the effusion of blood can not be discovered by palpa- 
tion ; it may, nevertheless, lead to retroversion and pro- 
lapse of the internal genitalia as a result of the acute 

175 



176 HEMATOCELE. 

stretching of the suspensory apparatus. I have frequently 
observed such cases in weak individuals after very heavy 
lifting and falling backward. The first symptoms are 
pain (lasting for days or weeks), discharge, and menstrual 
disturbances ; they may vanish, if the individual takes 
proper care of herself, to recur during the menses or after 
colds. Such cases offer a point of diminished resistance 
for puerperal or operative infections. 

Treatment. — The treatment consists of rest in the hori- 
zontal position with the head low. Restoratives (ammonia, 
ether) should be administered. Vaginal tamponade and a 
sand-bag upon the abdomen are recommended. Incision 
may be necessary. 



?2p. INTRAPERITONEAL RETROUTERINE 
HEMATOCELE. 

Definition and Etiology. — Intraperitoneal retro-uter- 
ine hematocele conies on suddenly without fever, usually 
following nonappearance of the menses, as a tense, elastic 
tumor, which bulges the recto-uterine pouch into the 
vagina and lies in close contact with the uterus. Eleva- 
tions of temperature may occur later, and brownish 
masses of blood are sometimes discharged from the uterus. 
The abdominal end of the tube not rarely projects into 
the effusion. The mass of blood is surrounded by layers 
of fibrin, — probably the result of successive hemorrhages, 
— and is walled off from the intestines by pseudomem- 
branes. Extra-uterine pregnancy is the usual, if not the 
only, cause (J. Veit) ; not rarely villi, or even an embryo, 
may be demonstrated. In a specimen extirpated at the 
Heidelberg Frauenklinik I was fortunate to find an 
embryo at most only three weeks old. (See Plate 57.) 
The uterus is displaced anteriorly. 

The hemorrhage is rarely profuse enough to pass over 
the broad ligaments into the vesico-uterine pouch. 

Other causes are hematosalpinx (in hematoraetra from 



SYMPT03IS.— DIAGNOSIS. 177 

atresia), ruptured varicocele or phlebectasia of the uterine 
adnexa, rupture of abdominal organs, and hemorrhagic 
pelvic pachyperitonitis (perimetritis). 

Symptoms. — Sudden appearance of symptoms of con- 
cealed hemorrhage, and pain, resulting from the peritoneal 
irritation. If the extra vasted blood is not infected from 
the bowel, from the tube, or from the parametrium, ab- 
sorption proceeds, with apyrexia ; infection produces vio- 
lent peritoneal pain and fever. 

From the uterus : continued discharge of changed blood 
(conducted to the uterus through the tube, according to v. 
Winckel). 

From pressure upon neighboring organs : neuralgia and 
dysmenorrhea (ovaries, see § 23 ; from the sciatic plexus 
into the thigh), disturbances of bladder and rectum. 

From further hemorrhage (as is especially the case after 
a previous perimetritis) : repeated sudden changes for the 
worse, until absorption occurs or rupture takes place into 
one of the hollow viscera (most frequently the rectum) 
with danger of septic infection. After absorption takes 
place a scar remains. 

Diagnosis. — Bimanual palpation should be most cau- 
tious, in order to avoid exciting further hemorrhage, rup- 
turing the fibrin capsule, or pressing infectious material 
out of the tubes. The posterior vaginal vault is very sen- 
sitive to the touch. All manipulations involving the use 
of the sound or calling for incision are to be avoided. 

The uterus is displaced anteriorly ; the posterior vaginal 
vault is pushed down by a tense elastic tumor. The space 
of Douglas is filled out in such a manner that the contour 
of the tumor is continuous with the uterine fundus ; con- 
sequently, confusion with a retroflexed gravid uterus may 
occur, especially if perimetritis coexists. (For differential 
diagnosis see Ovarian Cystomata.) The anamnesis and the 
foregoing symptoms are also to be borne in mind. If the 
tumor becomes smaller and nodular, with apyrexia, it 
speaks for hematocele. 
12 



178 HEMATOCELE. 

PLATE 58. 

Fig. 1.— Free Ascites in the Upright Position. In the dorsal 
position the fluid (serous or bloody) gravitates toward the spinal col- 
umn. The anterior border of the dullness on percussion is consequently 
lower. The border passes back in a line concave toward the chest 
(while tumors have an almost constant area of dullness, which is con- 
vex above). In the lateral position the border again shifts; the fluid 
seeks the lowest side, and the highest portion of the abdomen is tym- 
panitic (where dullness formerly existed). A wave of fluctuation 
may be obtained. 

Ascites occurs in malignant tumors (malignant papillary ovarian 
cystomata, cancer of the ovary, of the intestine, etc. ), peritoneal tuber- 
culosis, and exudative peritonitis (in addition to the obstructive dis- 
eases of the heart, lungs, kidneys, liver, portal circulation, etc.). 

If the fluid is an exudate (from an inflammatory process — tuber- 
culosis, for example), it contains red and white blood-corpuscles, cells 
of various sizes with fatty granules (individual cholesterin crystals), 
much fibrin and albumin, 1 and coagulates quickly; the specific gravity 2 
may exceed 1018 — a sign of its inflammatory nature. If the fluid is a 
transudate from stasis, it contains a few blood-corpuscles, flat endo- 
thelium from the serosa, no fibrin, and does not coagulate. 

Fig. 2.— Intraperitoneal Retrouterine Hematocele. (See 
Plate 57.) 

Fig. 3. — Extraperitoneal Retro= uterine Hematoma. Uterus 
retroverted and retroflexed. Douglas' pouch is free, but, like the 
vagina and rectum, it is bulged out by a fluctuating tumor, which 
can also be designated as a subperitoneal pelvic hematoma. This 
tumor is due to the tearing of vessels or organs or to the rupture of a 
phlebectasia. 

Fig. 4. — Large Subserous Posterior Myoma of the Uterus 
Simulating a Retroflexion. (Diagnosis made by sound! ) This is 
given for comparison with the other three retro-uterine tumors occupy- 

1 Determination of the amount of albumin : From 10 to 50 c.c. of 
fluid are diluted with ten volumes of water: heat to the boiling-point 
and add diluted acetic acid until reaction is slightly acid ; the precipi- 
tate is washed with water, ether, and alcohol ; it is then dried and 
weighed. 

2 The specific gravity is to be measured at room -temperature. If 
over 1018, inflammatory exudate, because it contains more albumin. 



Tab. 58. 




Fiff.l. 



Fig. 2. 




Fig,3. 



Fig A. 



lith. Anst. F. Reichfwld, Miinchen. 



TREATMENT. 179 

ing the pouch of Douglas. Anterior position of the uterus. Bulging 
of the vaginal vault into the rectum by a firm tumor, which grew 
gradually without fever. The tumor moves with the uterus: bi- 
manual examination demonstrates the connection. 

Treatment. — Absolute rest in bed and the avoidance 
of all internal therapeutic examinations and procedures. 
Ice-bag; enemata of opium, morphia, or chloral (to de- 
crease the heart's action). If the collapse continues and 
there are sufficient grounds for the supposition of an extra- 
uterine pregnancy (see "Atlas of Obstetric Diagnosis and 
Treatment " ). celiotomy. 

If perforation threatens, or if violent pain- and eleva- 
tions of temperature are present, and the tumor remains 
the same, the most prominent portion is incised through 
the vagina : the sac is drained and i- irrigated daily under 
low pressure. Ice-hag. bland diet, enemata. mild laxa- 
tives. If perforation into the rectum occur.-, no exami- 
nation should be made, on account of the danger of septic 
infection. 

Absorption is to be aided by the measures indicated in 
§18. Rest during subsequent menstruations, when fresh 
hemorrhages easily occur. 

Prognosis. — The earlier and more appropriate the treat- 
ment, the more favorable will be the prognosis for a com- 
plete absorption in several weeks or months. In perfora- 
tion it is dependent upon the degree of antisepsis that can 
be maintained ; rupture into the rectum is the most 
favorable. 



CHAPTER IV. 

FOREIGN BODIES IN THE GENITAL CANAL AND 
IN THE BLADDER. 

Foreign bodies in these organs may exert an injurious influence 
either from the injury attendant upon their entrance or from the in- 
flammation produced by their retention in the viscera. 



I 30. FOREIGN BODIES 

owe their introduction into the bladder, vagina, or uterus to a great 
variety of causes. 

(a) Retained instruments — pieces of vaginal nozles, glass specula, 
incrusted pessaries, needles, tampons, laminaria, retained silk sutures, 
incrusted pieces of catheter (especially the elastic ones). 

(b) Masturbation, perverse or criminal manipulations : hair-pins, 
needle-cases, candles, lead-pencils, fir cones, pomade boxes, spools ; 
tampons, sponges, and occlusive pessaries (to avoid conception) ; knit- 
ting-needles and other pointed instruments (to produce abortion). 

Tc) Falls — upon a pointed fence, for example. 

(d) Causes originating in the body : perforating tumors, such as 
dermoid cysts (teeth, hair, analogous to Plate 45, 2, into the rectum), 
extra-uterine gestation sacs, echinococcus-cysts, fistulas from other 
hollow viscera. Portions of the ovum remaining in the uterus are also 
to be classed under this heading. Vesical calculi. 

The consequences are depicted in \\ 22, 24, and 25 ; they are mostly 
inflammations, ulcerations, and fistulas. 

Treatment. — The removal of incrusted pessaries is described on 
page 87. 

The genital canal should always be disinfected by irrigation before 
any foreign body is removed (partly on account of the existing inflam- 
mation and fetid discharge, partly on account of the ease with which 
the mucosa may be injured). 

Foreign bodies are to be cautiously extracted with the fingers. If 
this is not successful, instruments (bullet-forceps or polyp-forceps, 
tenacula) are to be employed, carefully protecting the vagina from any 
sharp points. If the foreign body is a long one, it is to be grasped at 
one end. If this also fails, the object must be made smaller or the 
parts must be incised. In such cases deep narcosis is necessary. 

Foreign bodies in the bladder are diagnosed by the metal catheter, 
by bimanual palpation, by the cystoscope, or after urethral dilatation. 

180 



VESICAL CALCULI. 181 

(See § 22. ) The latter procedure is also necessary for their removal : 
bullet-forceps are introduced alongside of the palpating finger, and the 
foreign body is seized by one end, if possible, in order to prevent its 
becoming wedged transversely during extraction. The foreign body 
may be directly viewed through the speculum. It is sometimes ad- 
vantageous to fill the bladder with a boric acid solution. If the object 
is too large, it must be made smaller ; otherwise, colpocystotomy ; in 
children, suprapubic cystotomy. 

From an etiologic, symptomatic, and therapeutic stand- 
point vesical calculi differentiate themselves not only from 
other foreign bodies, but also from the same affection in 
the male. This difference is shown even in childhood. 
The shortness and the greater width of the female urethra 
allow concretions the size of a cherry-stone to pass, so that 
they are rarely able to become calculi by the continued 
accumulation of uric acid salts. 

Etiology and Symptoms. — All foreign bodies, includ- 
ing tumors and particles of mucus and pus in vesical 
catarrh, become incrusted with deposits of salts of uric, 
phosphoric, and oxalic acids as well as with cystin. All 
vesical catarrhs and other affections producing complete or 
partial retention of urine (vesical paralysis, cystocele, 
diverticula) are also causes of the formation of calculi. 
Calculi produce vesical catarrh, so that the symptoms of 
the latter are components of the clinical picture. 

The stone irritates the bladder ; hyperemia, hyper- 
secretion, hemorrhages, pain (local and radiating into the 
genitalia, sacrolumbar region, lower extremities), spasm. 
The local rubbing leads to ulceration, to perforating 
abscesses, and to the formation of fistulas. The urine 
contains clouds of mucus, pus, blood, ard squamous epi- 
thelium. 

Diagnosis. — This is made by bimanual examination, 
introduction of the catheter, cystoscopy, or direct inspec- 
tion through the speculum, the urethra being more or less 
dilated and the pelvis raised (Rose's procedure). (See 
§ 22.) The presence of a stone in a cystocele or in a 
diverticulum may be demonstrated by the cystoscope, or 



182 VESICAL CALCULI. 



PLATE 59. 

Fig. 1.— Left=sided and Posterior Parametritis. An inflam- 
mation of the parametrium (or paravaginal tissues — paracolpitis) arises 
from puerperal or operative infection (laminaria, intra-uterine pessa- 
ries), and extends into the broad and sacro-uterine ligaments. A yel- 
lowish, doughy, inflammatory exudate is formed (see Plate 61, 2, and 
Plate 40, 2), which displaces the uterus. Later, cicatricial contraction 
occurs, causing further displacement and angulation of the uterus as 
end-results of the process. Contraction of the sacro-uterine ligaments 
leads to anteflexion of the uterus ; of the septum between the blad- 
der and uterine neck, to retroversion or retroflexion. Other devia- 
tions arise if perimetritic adhesions are associated with the parame- 
tritis. 

Another termination may occur : The inflammation spreads behind 
the uterus into the pelvic connective tissue and beside the bladder. 
Abscesses are formed, which rupture into the vagina, rectum, or blad- 
der. They may perforate the abdominal wall above Poupart's liga- 
ment or gravitate to the thigh, to the pelvic floor, or through the sci- 
atic foramen, appearing beneath the gluteal muscles. 

The acute wound infection may have a fatal termination from severe 
septicemia. 

Fig. 2. — Intraligamentous and Retroperitoneal Multilocular 
Glandular Mucoid Cyst of the Left Ovary. This consists of a 
proliferation of the germinal epithelium of the Graafian follicle 1 or of 
the superficial cuboid epithelium of the ovary, together with prolifera- 
tion of the vascular and supporting connective tissue (see Plate 72) — 
cysto-adenoma. 

Fig. 3 — Left=sided Pyosalpinx. (See Plates 18, 19, and 39. ) 

Fig. 4. — Carcinomatous Cystadenoma of the Ovary. (Dia- 
grammatic drawing from a case in the Heidelberg Frauenklinik. ) 
The uterus is anteflexed and displaced anteriorly by a myxocystoma. 
The tumor has become malignant ; solid masses have grown into the 
floor of the recto-uterine pouch and have so surrounded the rectum 
that a rigid impermeable stricture exists. Ascites, numerous adhe- 
sions, and metastases to all organs are seen in such cases. In this case 
it was necessary to make an artificial anus. 

1 Stefleck demonstrated ovula in the young cysts of cystadenomata. 



Tab. 59. 





Fig 1 ■ 



Fig: 2. 




Fig.J. 



Fig. &. 



Lith. Anst. F. Retihtwld, Miinchen . 



TREATMENT. 183 

by means of catheters, after the bladder has been filled 
with 2 f boric acid solution. 

Treatment. — (a) Prophylactic: removal of causes, 
such as vesical catarrh, cystocele, foreign bodies, fistula. 

(b) Radical — removal of the stones : 

1. Through the urethra, after dilatation of the same. 
(See § 22.) 

2. By colpocystotomy — opening the bladder by a T- 
shaped incision in the vagina, the upper transverse arm 
being situated in the vaginal vault close to the anterior lip 
of the os uteri. If the stone is too large or the genitalia 
too small : 

3. Suprapubic cystotomy (sectio alta) is to be per- 
formed. The intestines are thoroughly evacuated, and 
350 gm. of a warm 2 f boric acid solution are introduced 
into the bladder in order to elevate it and its peritoneum 
above the symphysis. The incision commences at the 
symphysis and is from 5 to 7 cm. long, directly in the 
linea alba (or a transverse incision may be made — Tren- 
delenburg). The fascia transversalis is to be divided for 
1 or 2 cm. just above the symphysis. The catheter, 
already introduced into the bladder, is pressed toward the 
wound and the bladder-wall is incised. The edges of the 
vesical wound are to be firmly held. 

In this manner the anthor removed a stone larger than a man's 
thnmb, and bent npon itself at right angles, from a girl fourteen 
years of age. She had suffered from incontinence of nrine for five 
years, and was not more developed than a child of ten. The inconti- 
nence originally was due to prolonged chilling of the lower extremi- 
ties. The stone was adherent in a right-sided diverticulum. There 
was vesical catarrh, which caused a slight evening elevation of tem- 
perature and an increased pulse-rate. Several months after recovery 
the child had gained twelve pounds and presented a healthy appear- 



GROUP V. 

NEW GROWTHS. 



Etiology. — The origin of tumors of the female geni- 
talia, like that of tumors in general, is shrouded in dark- 
ness. It is nevertheless striking that organs which undergo 
such active and variable changes in form, structure, and 
metabolism, and which are exposed to so many mechanical 
injuries, bacterial invasions, and nervous irritations, can 
consequently easily lose their equilibrium of structure : L e. } 
the normal quantitative relation of the individual tissues. 

We observe proliferations in specific infectious inflam- 
mations (see §§ 12, 20, and 21) and in chronic congestive 
inflammations in general. (See Group III, chap. I and § 22.) 
We are able, further, to observe that in such inflammatory 
proliferations the normal relation of the epithelial to the 
connective tissues is gradually lost ; the new formation 
becomes atypical, and assumes a malignant character. 
(See Endometritis Fungosa and Erosio Papilloides, § 13 
and Plate 30.) In the same manner benign proliferations 
— myxofibromata, for example — may become sarcomatous ; 
pigmented nevi of the vulva have a great inclination to 
be suddenly transformed into the most malignant melano- 
sarcomata. Repeated cauterizations, excochleations, and 
unfortunate subsequent infections have without doubt not 
infrequently furnished the starting-point for a malignant 
metamorphosis. As in other epitheliomata, the malignant 
tendency is particularly liable to appear at the time of the 
menopause. 

A connection evidently exists between the origin of 
malignant epitheliomata and the liability of certain parts 

184 



ETIOLOGY. 185 

to injury, as is shown both by the predilection of these 
tumors for the vulva and cervix uteri and by the frequency 
of their occurrence in multipara. This is analogous to 
the predisposition to mammary carcinoma furnished by the 
scars of mastitis — whether we suppose the cause to be in 
the scar itself or in the original infection. 

The etiologies of the sarcomata and of the malignant 
cystomata are unknown ; the former are even relatively 
frequent in childhood or occur congenitally. Dermoid 
cysts seem to represent a variety of intrafetation. 

While the polyps of the mucous membrane are most 
frequently to be looked upon as circumscribed inflamma- 
tory proliferations (endometritis polyposa), there is no 
etiologic explanation for the proliferation of the muscularis 
uteri — for the myomata and fibromyomata ; indeed, their 
occurrence is far more common in women who have borne 
few or no children. Sterility (in spite of regular sexual 
intercourse) or the causes of sterility are, perhaps, re- 
sponsible for the tendency of the muscularis to proliferate ; 
secondary proliferation of the mucosa exists often enough, 
and this may be the cause of the sterility. 

It must be remembered that Ribbert and AVeigert, and 
recently Lubarsch also, consider the cause of the prolif- 
eration to be a decreased resistance to growth in the sur- 
rounding tissues. 



CHAPTER I. 



BENIGN TUMORS. 



By benign tumors, from an anatomic standpoint, we 
understand those that retain the typical structure of the 
tissue from which they arise, and that do not " eat up " 
all the surrounding tissues by a predominant proliferation, 
nor produce further destruction by metastasis. From a 
clinical standpoint, certain anatomically benign tumors 
may, nevertheless, be productive of pernicious results to 
the organism. This chapter treats only of the absolutely 
benign tumors. 



\ 31. BENIGN TUMORS OF THE MUCOUS MEMBRANES 
COVERED WITH SQUAMOUS EPITHELIUM (EPITHE= 
LIAL TUMORS OF THE BLADDER, VULVA, AND VA= 
GINA, AND TUMORS OF THE STRUCTURES EMBEDDED 
IN THEM). 

The mucous membrane, covered with squamous epithelium, lines 
the vagina, the vestibule, the bladder and urethra, and, in an ex- 
tended sense, the vulva. It consists of stratified squamous epithelium 
resting upon a matrix of cuboid cells, of the connective tissue of the 
cutis, which forms variously shaped papillae, and of adipose tissue. 
The embedded tissues are the lymph-vessels and lymph follicles ; 
blood-vessels, which in the clitoris, the nymphae, and in the neighbor- 
hood of the urethra form erectile cavernous bodies ; sebaceous glands — 
the two glands of Bartholin, lined with cylindric epithelium (see 
Plates 25 and 26) ; the similarly clothed small glands and ducts of the 
urethra (Skene's glands, see Fig. 20) and of the bladder (exceptionally, 
the vagina has glandulae aberrantes) ; and, lastly, muscle-fibers and 
nerves. The tumors now to be considered may arise in any one of 
these tissues. We accordingly differentiate : 

1. PapiUomata and condylomata, such as lupus of the vulva (see \ 12 
and \ 20 ; Plates 29 and 50) and, rarely, of the vagina. 

2. Condylomata {caruncle) of the urethra. (See Plate 51.) 

3. PapiUomata of the bladder. 

4. Fibromata, myxofibromata and fibromyomata of the vulva. 

186 



VAGINAL TU310RS. 187 

5. Fibromata, myxofibromala and fibromyomata of the vagina. 

6. Polyps of the mucous membrane or papillary polypoid angiomata, 
fibromata,, fibromyomata of the urethra. 

7. Polyps of the mucous membrane, fibromata, fibromyomata of the 
bladder. 

8. Lipomata of the vulva (usually with a pedicle) and of the vagina. 

9. Elephantiasis lymphangiectatica vulvae. (See Plates 29 and 51.) 

10. Cysts of the vulva ( of the glands of Bartholin ; of the glands about 
the clitoris and urethra ; occluded sebaceous glands of the nyniphse ; 
hydrocele of the inguinal canal) and cysts of the vagina (which in- 
cludes — the trimethylamin forming — colpohyperplasia cystica). 

11. Cystic myxo-adenomata of the urethra. 

12. Cysts of the vesical mucous membrane ( I found them once in the 
fetus, see v. Winckel's Ber. u. Stud., Munich). 

Diagnosis and Treatment. — The new growths of the 
vulva usually become polypoid, and are consequently 
easily removed with scissors, the knife, or the galvano- 
cautery (or Paquelhr's cautery) , the latter is particularly 
adapted for the removal of sessile or very vascular tumors. 

Fibromyomata of the vagina are rare; they may 
become so large that they lift the uterus up above the 
pelvic inlet and disturb the sexual functions as much as 
similar tumors of the bladder and intestine. If they have 
a broad base, they are to be shelled out from the surround- 
ing tissues. They sometimes show myxomatous degenera- 
tion. In every case it is to be carefully determined 
whether the tumor is really a vaginal one, or a myoma of 
the uterus which has been " delivered " into the vagina. 
The latter tumor may grow fast to the vaginal wall, lose 
its pedicle, and become a secondary vaginal myoma, 

Vaginal cysts vary in size and constitution according 
to their place of origin. They may be the remains of a 
duct of Gartner, having cylindric ciliated epithelium and 
serous contents ; of a vagina septa (see Fig. 20) ; or of a 
hematoma which has undergone partial absorption leaving 
behind a more or less blood-stained fluid. 

Treatment. — Enucleation. When that is impossible, a 
broad piece of the cyst-wall is excised and the cavity is 
packed. 

The tumors of the urethra are very sensitive and 



188 BENIGN TU3I0BS OF MUCOUS 3IEMBRANES. 



PLATE 60. 

Fig. 1. — Polyps of the mucous membrane are circumscribed prolif- 
erations of the endometrium, both of the body of the uterus and also 
of the cervical canal ; they consist of connective tissue containing nu- 
merous glands, partly cystic, and dilated, thin- walled capillaries. (See 
Plate 71, 1.) They form a pedicle by traction (see Fig. 52) and bleed 
easily on account of their structure. In contrast to polypoid rlbro- 
myomata, they are soft. They are livid from the constriction of the 
os uteri. 

Fig. 2. — Simple Erosion with Ovules of Naboth. Uterine 
fibroid on the point of dilating the os uteri : i. e. , about to be 
" delivered." (See Plate 62, 2 ; Plate 90, 4 ; Fig. 55.) 

bleed easily. The pain is often associated with itching, 
troublesome sexual excitement, or dysuria ; it radiates to 
the surrounding tissues, and may bring on convulsive 
attacks. Urination is painful, infrequent, or interrupted. 
If the tumors become larger, they project from the urethral 
orifice ; in other cases they may be drawn out with ten- 
acula, after incision or dilatation of the urethra. 

Treatment. — The latter procedures must be carried out 
preparatory to the removal of the tumors by ligation and 
Paquelin's cautery or the ecrasear (wire snare). 

Papillomata of the bladder first make themselves 



PLATE 61. 
Fig. 1. — Subserous Polypoid Fibromyoma of the Uterus. 

(Original drawing from a specimen in the Munich Frauenklinik. ) 
The tumor is composed of masses of concentrically arranged lamellae. 

Fig. 2. — Myomatosis Uteri. Parametritic swelling about the 
neck of the uterus and vaginal vault. Intramural myomata of the 
fundus ; submucous myoma of the fundus ; submucous polypoid fibro- 
myomata of the body of the uterus. The pedicle is elongated and 
twisted ; the tumors have dilated the os and have a dark bluish-red 
color from the constriction. (Original drawing from a specimen in the 
Munich Frauenklinik. ) 



Tab. 61. 











DIAGNOSIS.— TREATMENT. 189 

known by an indefinite feeling of pressure in the vesical 
region and by early disturbances of urination (increased 
frequency, tenesmus, ischuria). Violent radiating pains 
subsequently appear. From the ease with which the sur- 
face of the tumor may be injured, frequent hemorrhages 
occur, producing a particularly striking symptom, — hema- 
turia, — which may lead to a blocking of the urethra during 
urination by a mass of fibrin. The urine then undergoes 
decomposition and all the symptoms of vesical catarrh 
present themselves. Particles of the new growth may also 
occlude the urethra or cause the formation of calculi. 

Diagnosis. — When such symptoms are present, cystos- 
copy or dilatation of the urethra and palpation of the in- 
terior of the bladder. Microscopic examination of particles 
removed by means of the cystoscope. If the tumor is in- 
tact, not disintegrated, it is probably a benign growth. 
Perforating tumors, such as dermoid cysts and extra-uterine 
gestation sacs, are to be considered. 

Treatment. — The urethra is to be dilated ; the left in- 
dex-finger is then introduced into the bladder, and the 
tumor is removed by the wire ecraseur. If the tumor is 
sessile or too large, it is either to be incised or crushed 
bimanually. The hemorrhage is to be controlled by appli- 
cations of a solution of sesquichlorid of iron or of ferri- 
pyrin, by injections of ice-water, by an ice-bag upon the 
hypogastrium, and by firm tamponade of the vagina. If 
these methods are inapplicable, colpocystotomy or supra- 
pubic section. (See § 30.) 

Prognosis. — The removal of tumors by modern methods 
is sure, without danger to life, and without permanent in- 
continence ; the new growth easily returns, however, with- 
out showing a malignant structure, evidently because the 
bed of the tumor has not also been removed. 

S 32. BENIGN TUMORS OF THE UTERUS. 

As far as their consequences and removal are concerned, 
the only absolutely benign tumors are the mucous polyps 



190 



BENIGN TUMORS OF THE UTERUS, 



PLATE 62. 
Several Polypoid Myomata of the Fundus, Which Produced 
Uncontrollable Hemorrhage at the Time of the Menopause. 

Chronic metritis. Congestive swelling of the ovaries. (Original water- 
color from a case of total extirpation. ) 

(i. e., the smaller circumscribed proliferations of the 
mucous membrane) and the stationary subserous, the 
smaller intramural, and the small slender pedunculated 
fibromyomata. Of the remaining varieties of myomata, at 
least 10 ^S of the doubtful, often dangerous tumors are made 
up of the flat proliferating polyps of 
the mucous membrane (molluscum), 
and the large and broad-based fibro- 
myomata, especially the intramural 
and submucous varieties. 

The following are consequently 
benign : 

i. Mucous polyps (benign 
adenomata) : (a) of the lips of 
the os uteri ; (b) of the cervical 
and corporeal mucosa. (For 
Anatomy and Histology see Plates 
60,1; 67; 71, 1 ; 90 ; Fig. 52.) 
They are frequent, usually multiple, 
often combined with fibromyomata 
and projecting from them ; they usually remain small. 

Symptoms and Diagnosis.— Slight hemorrhages are 
frequent. Since many of these adenomata owe their 
origin to an endometritis fungosa or decidualis (decid- 
uoma, Ktistner), with or without the formation of cysts 
(ovules of Xaboth) (see Plate 90), we have a combination 
with the symptoms of this disease — above all, anomalies 
of menstruation. 

The adenomata of the lips of the os uteri represent 
glandular hypertrophies of these tissues, while those 
springing from the mucous membrane higher up hang 




Fig. 52.— Polyp of 

the mucous membrane 
of the fundus uteri. 



i 




I 



V 



N 







DIAGNOSIS.— TEE A TMENT. 



191 



from the latter by a pedicle. Upon this is based the diag- 
nosis by inspection. They are dark red, usually soft, 
and bleed very easily. As they are forced down against 
the os they produce a corresponding feeling of pressure 
and a reflex nausea. Frequently enough, however, such 
phenomena may be quite overlooked. 




Fig. 53. — Intramural myo- 
mata. The myomata of the 
nterns arise (according to v. 
Winckel) without exception 
in the muscularis of the 
corpus uteri and grow in 
various directions. (See Fig. 
54.) Cysts are seen in the 
proliferated cervical mucosa. 




Fig. 54. — Intramural myomata 
arising in the corpus uteri grow out 
of the wall in different directions : 
subserous, submucous, and down- 
ward into the wall of the cervix. 
They are all still inserted by a broad 
base and surrounded by circularly 
arranged fibrous tissue with widely 
gaping vessels. The mucosa is 
thickened. 



Treatment. — The easily accessible tumors with a ped- 
icle are to be removed by the wire snare, or they may be 
ligated and then removed by means of scissors. 

If the pedicle of the tumor is difficult of access (Fig. 52), 



192 BENIGN TUMORS OF THE UTERUS. 



PLATE 63. 
Intraperitoneal Surface of an Amputated Myomatous 
Uterus (Submucous Myoma). (See Plate 66.) The two surfaces of 
the incised uterus are drawn apart by the strong elastic retraction of 
the tumor. The cut surface of the tumors projects above the surround- 
ing tissues on all sides. . The ovaries and tubes are covered with 
small cysts. (Original water-color from a specimen removed by celiot- 
omy at the Heidelberg Frauenklinik. ) 

dilate the os uteri with well-sterilized laminaria or incise 
the commissures and enlarge the internal os with metal 
dilators ; then hold the lips of the os open with tenacula ; 
profuse hemorrhage is controlled by suture, Paquelin cau- 
tery, or applications of solution of sesquichlorid of iron ; 
firm tamponade with ferripyrin-nosophen gauze from 
twenty-four to forty-eight hours. 

Flat tumors are to be cureted (see § 13 (b)) ; then the 
gauze tamponade, as previously ; cysts are to be punctured. 
(Plate 90, 3.) 

All these tumors must be carefully removed with 
their pedicles, or they will recur. If the inclination to 
return is great, the parts are cauterized repeatedly with 
chlorid of zinc or solution of sesquichlorid of iron after 
the removal of the tumor. 

2. Fibromyomata with an Absolutely Benign 
Course. — Stationary intramural (parietal) myomata, 
small submucous or polypoid submucous fibromyomata, 
not causing marked hemorrhage, and small subserous or 
polypoid subserous fibromyomata. (See Fig. 53, and Plates 
14; 15, 4; 18, 1 and 2 ; 67 ; 90, 4.) 

Anatomy and Histology. — We differentiate histoid 
and organoid myomata. The histoid fibromyomata con- 
sist of nonstriated muscle-cells and of partly dense, partly 
areolar, connective tissue. (See Plate 71, 2.) They arise 
in the muscularis of the body of the uterus. They are at 
first intramural (intraparietal), and grow out in various 



Tab. 63. 







HISTOLOGY.— ETIOLOGY. 



193 



directions. (See Figs. 53-55.) They commence in the 
neighborhood of vessels, and their origin probably has 
some connection with vasomotor disturbances of growth. 
The organoid myomata are the adenomyomata (v. Reck- 
linghausen, 1896): i. e. y myomata with glandular and 
cystic inclusions, which v. Recklinghausen demonstrated 




Fig. 55. — The tumors commence to become pedunculated as poly- 
poid subserous and submucous fibromyomata. The myoma of the 
cervix, arising from gravitation, begins to shell itself out from its 
surroundings. Circular arrangement of fibers within the tumors. 



to be partly postfetal from the epithelium of the uterine 
mucosa, consequently derived from the epithelium of the 
Mullerian ducts (adenomyomata of the mucous mem- 
brane), and partly remains of the Wolffian body (paro- 
ophoritic adenomyomata). The adenomyomata are most 
13 



194 BENIGN TUMORS OF THE UTERUS. 



PLATE 64. 
Several Bleeding Myomatous Polyps of the Fundus. 

(Original water-color from a specimen in the Path. Inst, at Munich — 
Bollinger. ) 

intimately connected and interwoven with the muscularis ; 
they are not encapsulated, as are the histoid myomata. 

The adenomyomata of the mucous membrane may also 
be due either to a general or local penetration of the 
mucosa into the uterine wall, or to isolated, misplaced, 
fetal rudiments of the uterine mucosa (Landau), in which 
case the presence of a cytogenetic connective-tissue cap- 
sule speaks for their origin from the Mullerian ducts. 

According to location we differentiate : 

1. Intramural fibromyomata. (Figs. 53, 57 to 59, and Plate 61, 2.) 

2. Submucous fibromyomata. (Figs. 54, 55; Plates 63 and 66.) The 
tumor has a broad base and is still partly in the uterine wall. 

3. Polypoid submucous fibromyomata. (Fig. 55 and Plates 61, 2; 62, 
64.) The tumor has a pedicle and projects into the uterine lumen. . 

4. Cervical fibromyomata. (Figs. 54 and 55 and Plate 65.) The 
tumor (intraparietal) has gravitated into the cervical wall. 

5. Subserous fibromyomata (Figs. 54 and 55 and Plates 43 and 65.) 
The tumor causes a projection of the peritoneum. 

6. Polypoid subserous fibromyomata. (Fig. 55 and Plates 61, 1; 
67.) The tumor is connected to the uterus by a pedicle and projects 
into the peritoneal cavity. It may form adhesions with neighboring 
organs and thus have two pedicles ; if the primary pedicle becomes 
obliterated, the new growth seems to spring from the other viscus. 

7. Intraligamentous fibromyomata. The tumor grows in between the 
layers of the broad ligament. 

8. Intercorporeal fibromyomata in a double uterus. The tumor forms 
the septum. 



PLATE 65. 
Completely Extirpated Myomatous Uterus. The posterior 
lip of the os uteri (very anemic from profuse hemorrhages), as well as 
its appurtenant cervical wall, is transformed into a myoma larger than 
a man's fist. Adenomyomata at the insertions of the tubes. (Original 
water-color from an operative specimen at the Heidelberg Frauen- 
klinik.) 



Tab. 65, 




Lith.Anst F. Reichtwld, Miiiichen . 



SY3IPT0MS. 195 

A special group of the paroophoritic aclenomyomata is 
made up of the voluminous juxta-uterine and subserous 
varieties ; for both, although they pass diffusely into the 
uterine muscularis, may be isolated from it (Landau) ; 
they may separate themselves spontaneously and be found 
as solitary tumors in the broad ligaments. 

Isolated glandular and cystic deposits are found in his- 
toid myomata as accidental embryonic displacements of the 
epithelium, or analogous to the frequent combination of 
submucous myomata and " mollusca " of the neighboring 
endometrium ( Virchow), since the enveloping endometrium 
of submucous and polypoid myomata sometimes passes 
into the muscular tissue in a striated manner. 

Symptoms.— As can be deduced from the foregoing 
statements, these tumors throughout can be looked upon 
as " absolutely benign " only as long as they are small. 
Their earliest possible diagnosis and removal is conse- 
quently of the greatest importance. 

Initial Symptoms. — All the phenomena are independent 
of the size of the tumors. The most violent boring pains, 
produced by the tension, are particularly characteristic of 
the small intramural new growths. These pains are exag- 
gerated by all congestive conditions (menses, cohabitation, 
constipation) and by exploratory palpation of the uterus, 
which is neither necessarily enlarged nor displaced. These 
pains radiate into the surrounding tissues, and cause reflex 
neuralgias in the sacral and lumbar regions, in the face, 
etc. ; they make up a large part of the hysteric symptom- 
complex which is present in patients otherwise apparently 
in good general condition. 

Hemorrhage first appears as a menorrhagia ; later, as 
an irregular metrorrhagia. 

Cause. — Partly glandular endometritis over the tumor ; as soon as 
the last muscle-fibers between the new growth and the mucosa have 
disappeared, however, the proliferation of the interstitial tissue causes 
a fungous endometritis, or multiple adenomatous new growths (Wyder). 
In other cases the uterus is unable to contract sufficiently to close the 



196 BENIGN TUMORS OF THE UTERUS. 



PLATE 66. 
Inner Surface of a Uterus with an Incised Intramural Sub= 
mucous Hemorrhagic Myoma of the Posterior Wall. (See 

Plate 63. ) ( Original water-color from an operative specimen at the 
Heidelberg Frauenklinik. ) The anterior wall of the supra vaginally 
amputated uterus is opened, and the entire uterine cavity is filled by a 
round, tense, elastic tumor, which has been divided into two halves 
and thrown to each side. By bimanual palpation a deceptive fluctua- 
tion was apparent, due to the fact that the muscular tissue was com- 
pletely saturated with blood. 

vessels of the myoma (Landau). The contractility of these vessels 
themselves is evidently insufficient. 

These hemorrhages appear early, and, corresponding to 
their cause of origin, almost without exception in intra- 
parietal and submucous myomata. They frequently con- 
tinue after the menopause. 

If the tumor grows out of the uterine wall, escaping its 
tension, and is small and of the subserous variety, the ini- 
tial pains cease and there are no further pressure phe- 
nomena ; if it becomes submucous, distending the uterine 
cavity (Fig. 54), new labor-like pains appear and the leu- 
korrhea and hemorrhage become more profuse. These 
pains bring about a dilatation of the os uteri. (Plate 60.) 
If the tumor-tissue yields, the pedicle becoming long- 
drawn-out, the complete " delivery " of the mass occurs. 

Diagnosis. — Small intraparietal myomata, as well as 
diffuse homogeneous substitutions of the endometrium by 
adenomyomata, are not to be recognized by bimanual pal- 
pation. TTe suspect their presence from the apyrexia, 
with initial violent boring pains, and, later, monorrhagia 
and metrorrhagia. These symptoms demand the palpa- 
tion of the uterine cavity (after dilatation, with or without 
incision of the commissures of the os), which reveals sub- 
mucous or polypoid prominences, or different degrees of 
density of the uterine wall. 






H 




DIA GNOSIS. — TEE A T3TEXT. 197 

Later, the obliteration of the os uteri (Plates 60, 61, 
and Fig. 55) may be recognized by inspection. 

For differential diagnosis see page 219. Above all, 
pregnancy must be excluded before dilatation of the os 
uteri (menstruation is not absent, cervix is not so livid 
nor so soft). 

Treatment. — Prophylactic : ergotin subcutaneously 
(0.05 gm. daily, for months and years) to cause the tumor 
to contract and disappear. Ergotin also checks the hem- 
orrhage, as does stypticin and hydrastin — the former by 
exciting the involuntary muscle-fibers in the vessel-wall 
to contraction, the latter two through the vasomotor 
nerves. 

These measures are rendered more effective by hot vag- 
inal irrigations (117° to 127° F., one or more liters several 
times daily or every two hours), and, further, by depletives, 
especially before the period : mild laxatives, salt baths, 
salt inunctions, applications of alcohol. 

If the hemorrhages do not cease, the vagina is to be 
firmly packed with iodoform gauze or cotton tampons ; if 
this is without avail, cotton is wrapped about Playfair's 
aluminum sound, soaked in ferripyrin or chlorid of iron 
solution, and applied to the uterine cavity, or even left 
there for several hours. Ergotin subcutaneously and by 
mouth (as extractum secale cornutum 1 ). The author uses 
tampons the size of the finger, saturated with ferripyrin 
or gelatin emulsion. These are left until extruded by the 
uterus. 

If the uterine cavity is dilated and its walls are relaxed, 
ferripyrin, solution of sesquichlorid of iron, or gelatin 
should be injected by Braun ; s syringe. Great caution must 
be exercised : the syringe should not contain over two cubic 
centimeters of fluid ; the syringe is to be withdrawn as 
the injection is made ; it is better to inject into gauze 
(previously introduced) than against the mucous membrane. 

1 See Therapeutic Table. 



198 



BENIGN TUMORS OF THE UTERUS. 



Anemia resulting from hemorrhage is to be treated 
symptomatically, see § 4, under 7 ; for the dysmenorrhea 
and neuralgia see § 4, under 8, and, in addition, salt or 
brine baths (Kreuznach, Tolz) and applications of mud, 
brine, or hot alcohol to the abdomen. 

Fibroid and mucous polyps are to be removed by opera- 
tion. If the tumors are large, their size is to be decreased 
by longitudinal or spiral incisions or by the excision of 




Fig. 56. — Myxofibroma of the ovary with a long pedicle (rare). 
(Specimen at the Munich Frauenklinik. ) 

pieces, until the enucleation of the pedicle is possible. 
The uterine cavity is then to be disinfected and packed 
with iodoform gauze. 

Small submucous tumors are removed after dilatation of 
the cervix ; the overlying mucous membrane is incised, and 
the tumor is seized by the vulsella forceps of Muzeux and 
is shelled out of its bed. If the dilatation is insufficient, 



BENIGN TUMORS OF ADNEXA. 199 

the bladder is dissected free and the anterior cervical wall 
is divided to a point above the internal os. 

Cervical myomata that have grown into the parametritic 
connective tissue are removed after incision of the vaginal 
mucous membrane (Czerny). Vaginal tamponade. 

§33. BENIGN TUMORS OF THE UTERINE ADNEXA. 

The new growths proceed from the visceral serosa of the adnexa, 
with its subserous connective tissue, and the involuntary muscle-fibers 
of the broad and round ligaments; from the mucous membrane and 
muscularis of the tube; from the cuboid germinal epithelium of the 
ovary; and from the ovarian connective-tissue stroma. 

We have the following : 

1. Papillary proliferations of the tube: circumscribed or diffuse, with 
or without cyst formation in the tubal mucosa ; of an infectious nature. 

2. Fibromata and fibro myomata, including paroophoritic adenomyomata 
and adenomyomata of the mucous membrane (Plate 60) of the tube: soli- 
tary, from the size of a pea to that of a child's head; multiple, as a 
result of inflammatory proliferation (salpingitis nodosa, combined with 
hyperplasia of the mucosa and cyst formation) in the uterine isthmus 
of the tube, which is rich in muscle-fibers. 

3. Small fibromata and fibromyomata of the ovary may develop from 
the corpora candicantia or fibrosa. (Plate 40, 3.) Under certain con- 
ditions they may become very large ; they then lose their benign char- 
acter, partly because they show a tendency to malignant degeneration, 
partly because they act as an obstacle to delivery. They may have a 
cystic or cavernous structure. 

4. Fibromyomata and adenomyomata of the round ligament are very 
rarely intraperitoneal ; 1 they are more f recjuent in the inguinal canal. 

5. Fibromy.vomata and fibromyomata of the broad ligament may grow 
to the pelvic outlet and simulate hernias. The latter must not be 
confused with intraligamentous uterine myomata and adenomyomata. 

6. Lipomata of the tubes and of the broad ligament are rare; the former 
are only the size of a bean, the latter may weigh fifteen kilograms 
( thirty -three pounds ) . 

7. Cysts of the tubes and of the broad ligament, of serous origin (with 
the exception of the mucous cysts mentioned under 1 and 2), are small 
and only occasionally of importance, inasmuch as they may become 
pedunculated (hydatids, 2 such as Morgagni's) and contract adhesions 

1 I found such a tumor at autopsy. It was round, as large as a 
small potato, and in the middle of the broad ligament. This position 
is very rare (" Samml. d. Munch. Frauenklinik " ; v. Winckel's " Ber. 
u. Stud.," 1884-'90). 

2 This formation of hydatids is a frequent occurrence. I found 
them 45 times in 130 autopsies; in 8 of these several hydatids coex- 
isted ; in 3 cases 2 vesicles had the same pedicle. Several were calci- 
fied. Small cysts of the broad ligament were found 15 times ; 5 of 
these were calcified. I have seen them repeatedly in the fetus. 



200 BENIGN TUMORS OF ADXEXA. 

with the intestinal coils. Those cysts situated in the anterior layer of 
the broad ligament are to be considered as remains of the canals of 
the Wolffian body; the others, however, are to be looked upon as 
pedunculated fimbria with epithelial inclosures. 

8. Unilocular cysts of the ovary are dne to dropsy of the follicles. 
(Plate 68, 1.) The multil ocular cysts of the ovary are without sig- 
nificance only as long as they are small. 

9. Parovarian cysts arise from the remains of the Wolffian duct 
(probably also from the remains of the Wolffian bod}' between the 
parovarium and the uterus). These growths commonly remain small, 
but they may attain the size of a walnut or an apple and cause 
trouble. They are located between the ovary and the tube, and may 
be multiple. The cyst is always unilocular; the Avail is thin and 
consists of endothelium and subserous connective tissue with elastic 
and involuntary muscle-fibers; it is lined with either ciliated or non- 
ciliated cylindric epithelium. 

The contents are clear and are poor in albumin and consequently 
watery (of diagnostic importance regarding tapping). The fluid con- 
tains cylindric cells and has a specific gravity of 1005. 

Paroophoritic cysts are found in the course of the uterus as far as 
the upper portion of the vagina (Gartner's duct has been demonstrated 
up to this point in the fetus — Klein). Yeit includes in this classifica- 
tion the large vaginal cysts, which extend into the broad ligament. 

Symptoms and Diagnosis. — Ovarian fibromata, see 
Ovarian Cvstomata and the following section. 

Ovarian cysts (unilocular), see Ovarian Cvstomata ; also 
Oligocystic Degeneration, § 17. An ovary may show 
cystic changes without being enlarged. Nevertheless, 
pains exist, especially at the menstrual epoch, during 
palpation, or during defecation, which is usually difficult. 
These pains are referred to the sacrum, sometimes as the 
so-called " intermenstrual pain." (See § 17.) Dysmen- 
orrhea follows, or, if the disease is bilateral, amenorrhea 
and sterility. 

This painful affection, usually of an inflammatory 
nature, gradually stamps itself on the features of the pa- 
tient — -fades ovarica (lips pressed together, angles of the 
mouth drawn down and the surrounding skin correspond- 
ingly furrowed, wrinkled and furrowed forehead, sunken 
cheeks, prominent cheek-bones, and pointed nose). 

If the tumor attains the size of a child's head, symp- 
toms arise from the displacement of the uterus and from 



VIA GNOSIS. — TEE A TMENT 201 

pressure upon the rectum, bladder, vessels, and nerves 
(desire to urinate, constipation, hemorrhoids, phlebectasia, 
neuralgias in the lower extremities, etc.). It is at this 
point that the ovarian cysts cease to be unimportant. 

The diagnosis of ovarian cysts is made by bimanual 
palpation (also through the rectum). A pedunculated 
tumor is found beside the uterus ; the tumor replaces the 
ovary of this side. 

Parovarian cysts first give rise to symptoms when they 
reach to the pelvic inlet. They produce disturbances of the 
circulation in the broad ligament, and consequently inter- 
fere with the nutrition of the ovary. This results in 
anomalies of menstruation. 

They may be recognized as fluctuating tumors at the 
side of the uterus, distinctly differentiated from it, and 
upon puncture yield a fluid with the previously described 
characteristics. They rarely return after being tapped. 

Treatment. — Parovarian cysts may be tapped. 
Those containing a fluid richer in albumin are to be 
removed by celiotomy. If the tumor has a pedicle, the 
operation is a simple one. If strong adhesions exist, re- 
move as much as possible and unite by suture. [Celi- 
otomy and complete removal should take the place of 
tapping. — Ed.] 

Intraligamentous cysts are to be dissected out from the 
surrounding connective tissue, or the corresponding portion 
of the broad ligament is to be excised. 

Ovarian cysts not larger than an apple are to be removed 
only when the disturbances they produce are unbearable. 
Iodid of potassium is to be given in solution or in vaginal 
suppositories (as an absorbent) until iodism is produced. 
To alleviate the disturbances : warm fomentations to the 
abdomen and applications of iodin ; rest during the 
periods. If pelvic peritonitis appears, rest in bed and 
the ice-bag are indicated. Regular movements of the 
bowels are to be secured. (See also § 35.) [Ovarian 
cysts presenting symptoms should be removed. — Ed.] 



CHAPTER II. 

TUMORS OF BENIGN STRUCTURE THAT MAY 

BECOME DANGEROUS UNDER CERTAIN 

CONDITIONS. 

§34. THE FIBROMYOMATA. 

All the large, progressively increasing myomata of the 
vagina, uterus, and ovary that are not polypoid (intraliga- 
mentous and intraparietal growths, and those with broad 
bases) belong to the group of fibromyomata that are fol- 
lowed by serious consequences (mortality, 10^). 

The dangerous results of these tumors are : 

1. Extreme anemia and secondary cardiac disease, pro- 
duced by the continued hemorrhage (later, the dilated, 
thin- walled vessels may rupture). 

2. Hemorrhages may also occur into the substance of 
the tumor. (Plate 66.) The cause is usually a distur- 
bance of the circulation with thrombosis (this sometimes 
leads to fatal emboli after operation). These extravasa- 
tions suppurate easily, and thus cause sepsis. 

3. Torsion of the pedicle 1 in large subserous polyps 
leads to necrosis and inflammation ; in the submucous 
polyps, to ulceration and putrefactive gangrene. 

4. Inflammatory adhesions are formed with the intes- 
tines. 

5. Submucous polyps may lead to inversion of the 
uterus (Figs. 24 and 57-59) if they proceed from the fun- 
dus and if the formation of a pedicle is made difficult by 

1 There are cases in which the uterus itself, instead of the pedicle, 
is twisted about its axis, or even torn open at the internal os. The 
tumor may become separated from the uterus, and obtain its nourish- 
ment through previously existing intestinal and omental adhesions. 

202 



FIBE0JIY03IA TA. 



203 




Fig. 57. — Intramural nbromyoma of the uterine fundus, projecting 
into the vagina. Mm, Os uteri. 




Fig. 58. — Multiple intramural myomata of the fundus. Submucous 
myoma of the fundus projecting into the vagina. Mm, Os uteri. 



204 FIBEOMYOMA TA . 

PLATE 67. 
Polypoid Subserous Fibromyoma ; Polyps of the Mucous 
Membrane in the Dilated Cervical Canal. (Original water-color 
from a specimen at the Path. Inst, at Heidelberg. ) 

numerous strong muscle-fibers from the uterine muscularis 
extending into the tumor. Further consequences : pres- 
sure necrosis, gangrene. 

6. The large size of the tumor (some of them may weigh 
eighty-five pounds, especially if they are the seat of cystic 
degeneration) may cause obstruction or distortion of the 
pelvic organs, 1 or may interfere with delivery. They are 
particularly dangerous when they are calcified. 

Cysts arise from myxomatous degeneration, from absorbed extrava- 
sations, or from the edematous softening of muscle-fibers (due to com- 
pression or infectious thrombosis of the vessels). 

7. Intramural tumors may undergo fatty or calcareous 
changes, remaining stationary or becoming smaller. They 
may be the seat of myxomatous degeneration ; they then 
show an inclination to be transformed into myxosarcomata 
(Plate 87, 2 ; 73, 1), sometimes with intermuscular pseudo- 
cysts (Plate 73, 3), which arise from the destruction of 
round cells or from blood extravasations. 

8. The central portions of the tumor may undergo 
primary metamorphosis into a fibrosarcoma. Primary 
carcinomatous degeneration of the tumor itself or of the 
proliferated uterine mucosa may take place. Malignant 
degenerations occur at the menopause in 4| <f of all cases 
(Fehling). 

9. The dangers of operative removal are hemorrhage 
and suppuration. If the tumors are sessile or are located 
deep in the uterine wall, necessitating the opening of the 
uterine cavity, peritonitis may occur, either from primary 

1 Occlusions of the intestines, bladder, and ureters, which lead to 
intestinal obstruction, absolute retention of urine, uremia, inconti- 
nence with secondary cystitis, pyelonephrosis, etc. 



Tab. 67. 




Lith.An.st tl ReidihoUl, Miinchen. 



DA NGEES. —S YMPTOMS. 



205 



infection or from the later rupture of an abscess of the 
stump. 

Finally, lung emboli are more common than in opera- 
tions upon other large genital tumors. All these dangers 
are more pronounced when the patient is profoundly 
anemic. 

Symptoms.— Vaginal myomata — only pressure symp- 
toms. 

Large uterine myomata (for initial symptoms see § 31). 
If intramural, monorrhagia, and, in addition, pressure 




Fig. 59. — Intramural fibroin voma of the fundus uteri producing an 
inversion of the uterus. Jim. Os uteri. 



symptoms, as in all these larger tumors. (Plates 63 
and 66.) 

If submucous, menorrhagia and metrorrhagia with vio- 
lent colicky pains, as the tumors twist the uterus and often 
occlude the outlet for the discharge. Slight perimetritic 
pains are present. Sterility or abortion is frequent. The 
tumors easily undergo suppuration during the puerperium. 

If submucous and polypoid, all the symptoms of the 
simple submucous variety, and, in addition, labor-like 



206 FIBBOMYOMATA. 

pains, since the uterus tries to expel the pendulous myoma. 
When the polyp lies in the vagina, it becomes edematous 
and the seat of a foul ulceration. A constant, nonremit- 
tent fever exists even when a fetid discharge is not pres- 
ent. This is due to interstitial infection of the tumor. 
(Plate 61, 2.) Catarrhal discharge is profuse because the 
irritation of the fibroid polyp causes the mucous mem- 
brane to proliferate in toto. Multiple mucoid polyps may 
consequently arise. 

If subserous, the symptoms are few, often not more 
marked than the pressure symptoms of the pregnant 
uterus (dyspnea ; reflex irritation of the breasts is not 
often absent). The tumor may irritate the peritoneum or 
may produce reflex neuralgias from pressure. 

In cervical myomata, menorrhagia and profuse leukor- 
rhea. (Plate 65.) 

With very rare exceptions the tumors contract during 
the menopause ; the climacterium is, nevertheless, not 
rarely prolonged by marked hemorrhages. The author 
saw regular periods from this cause in an American 
woman, fifty-seven years of age. 

In ovarian fibromyomata the symptoms are very uncer- 
tain : sometimes absence of the menses or ascites. 

Diagnosis. — Vaginal Myomata. — It must be deter- 
mined whether the tumor actually springs from the vag- 
inal wall, or is simply adherent to it, as uterine polyps 
may contract secondary adhesions with the vagina. 

Intramural Uterine Myomata. — The wall of the organ 
is hypertrophied and the uterine cavity is elongated. 
Metritis and pregnancy must be excluded. In the former 
the wall is not so dense and the sound is not made to 
deviate from the straight line by the presence of a tumor. 
In the latter the cervix is livid and the entire organ is 
strikingly soft ; the increase in size occurs in a typical 
way ; the menses are absent. 

If one suspects submucous or polypoid myomata, the 
uterine cavity is to be palpated after dilatation of the cer- 



DIAGNOSIS. 207 

vix. The sound is to be passed first ; the cavity is en- 
larged, but the sound passes around the tumor or can not 
effect an entrance. At the menstrual epoch the tumor 
separates the lips of the os (Plate 60, 2; 61); traction 
with the bullet-forceps gives information as to whether the 
tumor has a long pedicle or a broad-based insertion. 

If such tumors are very large (Fig. 57), and if they 
project far into the vagina, it is often difficult to determine 
their true origin without bimanual examination through 
the rectum and the employment of the sound. 

Cervical myomata, especially if they have undergone 
suppuration, must be distinguished from epitheliomata of 
the cervix. The former have a pedicle leading into the os 
uteri ; when broken down, they have a loose fibrous 
structure and a brownish-red or pale rose color. The epi- 
theliomatous nodules are softer ; they crumble and bleed 
easily ; they are always outside of the external os ; they 
undergo ulceration without the production of polypoid 
excrescences. The microscope shows fibrous tissue in the 
one case, epitheliomatous plugs of cells in the other. (Plate 
71, 2 ; 79.) Fibromyoma differentiates itself from sarcoma 
by its greater density, slower growth, painlessness, and 
absence of foul discharge with particles of tissue. The 
transition from myoma to sarcoma is consequently char- 
acterized by the appearance of these symptoms and by 
ascites. Fibromyomata have been mistaken for placental 
polyps, and also for inversion of the uterus. .(For diagnosis 
of the latter see § 7.) Placental polyps, like polyps of the 
mucous membrane, are softer. They contain decidual 
cells, glandular epithelium, and chorionic villi. 

It is often difficult to diagnose subserous eincl intraliga- 
mentous uterine myomata from tumors of the adnexa and 
from tumors of the pouch of Douglas. This is partly 
owing to the fact that they completely fill the rectovaginal 
culdesac, and partly because they may be embedded in the 
exudate of a pelvic peritonitis. (For differential diagnosis 
see following section, under Ovarian Cystomata.) The 



208 FIBROMYOMATA. 

sound demonstrates the course of the uterine canal, so that 
we know where to look for the tumor and where to look for 
the uterus. (Plate 58, 4.) 

Bimanual examination is employed to determine 
whether the uterus moves with the tumor. This method 
of examination is of especial importance if the tumor is a 
subserous polyp with a long pedicle. (Plates 61 and 67.) 
The density of such tumors is also to be observed. Fi- 
broid cysts or very edematous tumors may show fluctuation, 
thus resembling ovarian cysts. 

The diagnosis is made by tapping. The fluid from the 
cystic myoma is lymph ; it coagulates and contains only 
lymph-corpuscles. In simple myomata nothing is ob- 
tained but blood. The differential diagnosis from ovarian 
fibromata is sometimes impossible. 

A vascular bruit may be heard upon auscultation in 
66^ of all myomata; rare in cystomata. 

If a myoma undergoes suppuration, it becomes intensely 
painful and fluctuates. Septic jaundice and fever make 
their appearance. 

Ovarian Fibromata. — The chief point is the ovarian 
origin of the tumor. The further diagnosis is made by 
the density of the new growth. 

Treatment. — Operative interference is indicated if the 
treatment with ergotin (Hildebrandt), as given in the 
previous section, is fruitless and the tumor continues to 
grow and to produce threatening symptoms. This treat- 
ment is to be considered useless if the menorrhagia is not 
decreased by the daily injection of 0.2 gm. of ergotin for 
two months (i. e., after at least from sixty to eighty injec- 
tions). 

The larger submucous tumors are to be removed piece- 
meal through the vagina (fifty-two pieces in one of v. 
Winckel's cases) ; suppurating tumors are to be cautiously 
removed by means of the polypus-forceps under contin- 
uous irrigation — colpomyotomy. 



TREATMENT. 209 

Enucleation, in the true sense of the word, is often impossible, as 
the intramural and submucous myomata are rarely, the adenomyo- 
mata never, encapsulated. It is difficult to remove the tumor, as 
the finger works in the uterine wall in the dark. Hemorrhage is 
controlled by injections of hot water and by tamponade. Sepsis occurs 
only too easily. 

If such a case is foreseen, it is better to incise the overlying mucous 
membrane, to administer ergot, and to allow the uterus to expel the 
tumor. The tumor may be made smaller by morcellement (Pean) 
and the uterus removed. Ligation of both uterine arteries is recom- 
mended as a palliative measure. 

There are three methods for the removal of the tumor by celiotomy : 

I. Myomotomy : i. e., removal of the tumor from the uterus, which is 
left uninjured. 

II. Supravaginal amputation of the uterus : i. e., removal of the uterine 
body, together with its myoma, from the cervix. 

III. Total extirpation of the uterus (Fritsch, Kiistner, Martin, Mack- 
enrodt). 

IV. Castration: i. e., the removal of both ovaries. A premature 
menopause is produced, since experience teaches that myomata fre- 
quently grow smaller at this time. This measure is not absolutely 
certain in its results. 

It must be carefully determined whether the disturbances and dan- 
gers due to the tumor are greater than those of the operation (embol- 
ism ; fatal hemorrhage ; sepsis, especially from the opened uterine 
cavity, see foregoing). 

Indications for the operations : 

1. Severe exhausting hemorrhages. 

2. Inability to work. 

3. Such rapid growth that life is apparently threatened, especially 
in cystic degeneration. 

4. Abscess formation in the tumor. 

5. Torsion of the pedicle with symptoms threatening the life of the 
patient. 

I. Myomotomy is applicable to subserous polyps and to those sub- 
serous and intramural myomata that may be shelled out of the uterine 
wall. (Plate 61, 1; 67.) 

If the uterine cavity is opened, or if only the mucous membrane 
remains as a thin layer — 

II. Supravaginal amputation is to be performed. 

The question of the necessity for and of the manner of amputation 
frequently remains undecided until the abdominal cavity is opened. 
It is indicated in the broad-based subserous tumors, in the large or 
multiple intramural growths, and in intraligamentous or degenerated 
(cystic, cavernous, carcinomatous, supjmrating) myomata that do 
not project into the uterine cavity. (Plates 63, 66.) 

An elastic tube is applied about the uterus and adnexa (laterally 
from the ovaries). The broad ligament is then ligated close to the 
uterus ( Z weif el ) in three portions, from the suspensory ligament of the 
ovary ( inf undibulopelvic ligament) to a point as low down as possible, 

14 



210 FIBROMYOMATA. 

PLATE 68. 

Fig. 1. — Unilocular Ovarian Cysts. Two cysts were situated 
in such a manner that one of them forced its way into the other. 
(Original water-color from an autopsy at the Heidelberg Path. Inst. ) 

Fig. 2. — Thin=walled Multilocular Glandular Mucoid Cyst. 
The pedicle, together with the tube and a hydatid, lies upon the tumor. 
The furrow is due to the impression of the iliopectineal line, as the 
smaller portion of the cyst was in the pelvis and filled the pouch of 
Douglas. (Original water-color from an operative specimen.) 

and the uterus, with tumors and adnexa, is removed. If intraliga- 
mentous tumors are present, the broad ligament is incised and ligated 
on both sides in three portions. 

The stump may be treated according to various methods : 

1. Schroder's Intra peritoneal Method. — Wedge-shaped excision (cau- 
terizing the stump with concentrated liquid carbolic acid, zinc chlorid, 
or Paquelin's cautery). The mucosa, the muscularis, and the serosa 
are sutured separately ( etage suture ) with catgut. 

There is danger of secondary infection : i. e., of abscess formation 
in the stump and. rupture of the united serosa. A large stump should 
consequently be avoided, as portions of it may undergo necrosis. 

2. Pean-Hegars Extraperitoneal Method. — Long needles are passed 
through the stamp at right angles, fixing it in the lower angle of the 
abdominal wound outside of the peritoneum. The serosa of the stump 
is sutured to that of the abdominal wall. The stump is covered only 
by the abdominal muscles. 

It undergoes necrosis and is cast off, together with the elastic tube, 
after two or three weeks. 

The disadvantage of this method consists in the permanent traction 
upon the bladder. 

Fritsch unites the stump as does Schroder, using- sagittal instead of 
transverse sutures, and sews it into the lower angle of the abdominal 
incision. On the ninth day he removes the coaptation sutures of the 
stump from the bottom of the wound. 

3. Chrobak fixes the stump behind the peritoneum (consequently 
an extraperitoneal method) by covering it with a peritoneal flap pre- 
viously excised either from the tumor or from the uterus. 

III. Total extirpation guarantees the greatest security against sec- 
ondary infection of the peritoneal cavity from the secreting or partly 
necrotic stump obtained by the supravaginal method : l it is. however, 
a more radical operation. In certain cases it is absolutely indicated, 

1 At the Heidelberg Frauenklinik. in 1896, thirty myomotomies were 
performed (the stump being treated by the retroperitoneal method) 
with two deaths, one from pulmonary embolism, one from severe 
anemia. 



00 




TREATMENT. 211 

as in pyosalpinx (Plate 42) and cervical myomata (Plate 65). The 
ovarian arteries are ligated, transverse incisions are made in the vesico- 
uterine and recto-uterine excavations, and the ligaments are successively 
ligated and divided. The neck is amputated in such a manner that a 
very small portion remains behind with the external os (the orifice 
may be cauterized ) . This wound is to be united by some nondraining 
suture material (silkworm-gut). Catgut ligatures are used in the 
parametritic cellular tissues and in the serosa. 

IV. Hegar's castration is only a makeshift. It is to be performed 
only when the removal of the myomata must be looked upon as 
dangerous to life (very large myomata with multiple subserous nod- 
ules preventing their removal from the pelvic cavity). The operation 
has a mortality of 16 % , because the ovaries are frequently so close to 
the tumor that the ligation of the vessels is very difficult. In many 
cases the looked-for result has failed to appear. The ligation of the 
uterine arteries from the vagina is a better operation ( Gottschalk ) . 

The operative removal of ovarian fibromata is indi- 
cated, even if they are of only moderate size and station- 
ary, on account of the danger of malignant degeneration. 
Hemorrhage, especially from the adhesions, is the chief 
danger of the operation. The elastic rubber tube is used, 
and the pedicle is tied off with broad, strong ligatures 
before the removal of the tumor. 

The preparatory treatment and after-treatment in all 
these celiotomies are the same as in the removal of ovarian 
cystomata. 

§ 35- THE OVARIAN CYSTOMATA. 

Definition, Anatomy, and Histology. — The multi- 

locular glandular mucoid cyst arises from a proliferation 
of the germinal epithelium of the Graafian follicle, 1 
together with a supporting and vascular proliferation of 
the connective tissues (see Plate 72) — cystadenoma. 

Five varieties of ovarian cysts may be differentiated : 

1. Unilocular cysts (Plate 68, 1) — hypertrophic ovarian follicles 
( hydrops f olliculomm ) . 

2. The multilocular glandular mucoid cyst — a nodular complex of 
many smaller cysts, filled with viscid mucus (greenish-yellow to 
grayish-black according to the admixture of blood) and surrounded 
by a single outer wall. (Plate 72.) 

1 Steffeck demonstrated ovula in the young cysts of cystadenomata. 



212 OVARIAN CYSTOMATA. 



PLATE 69. 
Multilocular Glandular Mucoid Cyst. As a result of torsion 
of the pedicle, hemorrhages have occurred in individual cysts ( dark- 
bluish color) and portions of the wall have become necrotic and adher- 
ent to the omentum. Subperitoneal disturbances of the circulation 
have formed cystic spaces (on the left) in the latter. (Original water- 
color from a case at the Heidelberg Frauenklinik. ) 



The tumors show a more or less rapid, progressive, 
and almost unlimited growth. They become dangerous 
when they grow larger than a man's head ; their weight 
may exceed that of the patient herself. (Fig. 62.) AVhen 
the tumor has involved the entire ovary, it is fixed to the 
uterus and nourished by a pedicle, which consists of the 
broad ligament, tube, and ovarian ligament. The pedicle 
is absent in intraligamentous tumors (Plate 59, 2) because 
the entire growth develops outside of the peritoneum in 
the subserous connective tissue of the broad ligament. 
The anterior surface of the ovary is embedded in the 
broad ligament (by the mesovarium), while the posterior 
surface, directed toward the pouch of Douglas, is uncov- 
ered. If an ovarian cyst develops from the anterior 
surface, it grows into the connective tissue between the 
two layers of the broad ligament — it is " intraligamen- 
tous " ; if the tumor becomes larger, it strips up the pos- 
terior lamella, elevates the serosa of Douglas' pouch, and 
reaches the spinal column — it becomes " retroperitoneal/' 

The pedicle previously mentioned is pathognomonic of 
ovarian tumors, and may be demonstrated by the method 
illustrated in Plate 74. It is usually twisted in a spiral 
manner in the larger tumors. This torsion of the pedicle 
is due to intestinal peristalsis, to the variable emptying and 
filling of the abdominal organs, and to the movements of 
the body. In left-sided tumors the pedicle is more 
frequently twisted from 90 to 180 degrees to the right. 
If it is twisted more than 360 degrees, disturbances of the 



SEQ UELS. —SYMPTOMS. 213 

circulation and extravasation occur in the tumor, and 
hematomata are formed in the pedicle ; secondary dis- 
turbances of nutrition lead to retrograde metamorphoses ; 
both results are serious in proportion to the rapidity of 
the compression (necrosis ; rupture of the mucoid degen- 
erated wall, Plate 72 ; decomposition ; peritonitis). If 
colloid masses reach the peritoneal cavity, they become 
organized upon the serosa, constituting " peritoneal myx- 
edema" (pseudomyxoma peritonei, "Werth). 

The larger tumors always cause fibrinous deposits and 
adhesions, because the changed superficial epithelium be- 
comes desquamated. In a beginning cystoma the fim- 
briated end of the tube sometimes becomes agglutinated ; 
if the dividing wall disappears, a tubo-ovarian cyst re- 
sults. 

3. Papillary proliferating cysts. (See explanation to Fig. 61.) 

4. Racemose cysts (Olshausen) differentiate themselves from the 
cystadenomata by the fact that several vesicles are attached to one 
pedicle ; even if they have broad bases, they do not present a smooth 
globular surface, but look like a mass of small vesicles (resembling a 
hydatid mole). The vesicles contain a fluid that is not colloid; it is 
rich in albumin. 

5. Dermoid Cysts. (Plates 45 and 79.) 

Cystomata may lead to serious consequences : 

1. From their increase in size — larger than a man's 
head. 

2. From strangulation as a result of torsion of the 
pedicle, with hemorrhages, inflammation, suppuration, in- 
fection (they may, it is true, undergo absorption and nat- 
ural cure), septicemia. 

3. From intestinal adhesions and the subsequent pro- 
duction of intestinal obstruction. 

4. From rupture of the tumor and consequent pseudo- 
myxoma peritonei (Werth). 

5. From carcinomatous degeneration. 

6. Death from cardiac weakness, uremia. 
Symptoms. — (See initial symptoms in § 32.) Pressure 

symptoms first occur when the tumor reaches the size of 



214 OVARIAN CYSTOMATA. 

PLATE 70. 

Multilocular Glandular Mucoid Cyst. The middle of the tumor 
is laid open by an incision. ( Original water-color from an operative 
specimen from the Heidelberg Frauenklinik. ) 

PLATE 71. 

Fig. 1.— Histologic Structure of a Uterine Mucous Polyp. 

( Original drawing from a specimen from the Munich Frauenklinik.) 
Circumscribed proliferation of the uterine mucosa (proceeding from the 
body as well as from the cervix ) , consisting of glandular and connective 
tissue in their normal structure and relations ( in contrast to the atypi- 
cal proliferation of malignant adenoma, as seen in Plate 30, Fig. 2). 
The glandular spaces (1) are lined with ciliated columnar epithelium. 
Numerous thin-walled, dilated vessels (2 and 4) are seen in the con- 
nective tissue (3), and are responsible for the hemorrhage that is so 
easily produced. 

Fig. 2. — Microscopic Section through the Transition Zone 
of a Minute Myoma That is Becoming Encapsulated into 
the Surrounding Normal Uterine Muscularis. (Original draw- 
ing from a specimen from the Munich Frauenklinik.) The tumor 
tissue to the left (1) consists of densely packed and interlaced non- 
striated muscle-fibers alone, without the admixture of connective-tissue 
fibers that occurs without exception in the large tumors (consequently 
called fibromyomata, which always originate in such pure intramural 
my omata ) . The border-line ( 2 ) of the normal muscular tissue consists 
of concentrically arranged parallel lamellae, which are evidently com- 
pressed by the new growth. To the right, markedly dilated vessels 
(4) are seen in the muscularis (3), which shows a less parallel arrang- 
ment. 

Fig. 3.— Vaginitis (Colpitis). (Original drawing from a speci- 
men from the Munich Frauenklinik. ) Eound-cell infiltration of the 
submucous connective tissue, especially in the neighborhood of the 
numerous normal lymph-follicles (3— surrounded by round cells and 
lymph-channels). (1) Normal vaginal tissue ; (2) normal connective 
tissue. 



Tab. 71. 




Fig.l. 



i 






K' .•'.:' hl--u? $$M In- .Mt : 



-U 



X 






. ■ /. ■ .. - 






m 



Fig.Z. 




Fiff.3. 

Lith.Anst.F. Reiehhold . Munrhen . 




Fig. 60. — Multilocular glandular mucoid cyst of the ovary, v 
torsion of the pedicle. (Specimen at the Munich Frauenklinik. 

215 



, with 



216 



OVARIAN CYST03IATA. 



a child's head and remains wedged in the pelvic cavity 
(constipation, urinary disturbances, neuralgias). Intes- 
tinal perforation may occur. (See Plate 45, 2, represent- 
ing a case treated in the dispensary at the Munich Frau- 
enklinik.) Dyspnea, swelling of the thoracico-abdominal 
veins, edema, and pressure upon the ureters are observed. 
The patient is finally confined to bed. 




Fig. 61.— Papillary proliferating cyst (specimen from the Munich 
Frauenklinik), characterized by the fact that the epithelium produces 
not only glandular— i. c, follicular and cystic— formations, but also 
conglomerations of papillary formations upon the walls of the cysts. 
(See also Plate 72, Figs. 1 and 2. ) These dendritic proliferations are 
found either only upon the inner surface of the cysts, or also upon the 
outer surface; in the latter case they not rarely grow through the wall. 
They give metastasis to the serosa of the entire peritoneal cavity and 
produce ascites. Macroscopically, they are not to be differentiated 
from the similar, somewhat firmer, carcinomatous growths. 

The diagnosis is made by the demonstration of a 
pedicle and the separation of the tumor from the uterus, 
the method of Schultze being employed. (Plate 74, 
Fig. 3.) Fluctuation is a further aid. In contrast to 
ascites, percussion demonstrates an area of dullness which 



Q 



& 




217 



218 



OVARIAN CYSTOMATA. 



has an upper convex border ; above and at the sides an 
intestinal tympanitic note may be obtained. Ascites may 
coexist. Vascular murmurs are much rarer than over 
myomata. 

The uterus is usually found in front of and beneath the 
tumor (Plate 59) ; it is rarely retroverted (Plate 16, 4) ; 
if pregnancy occurs, total prolapse may take place. The 
uterus does not move with the tumor. The pedicle arises 
from one corner of the uterus (Plate 74, 3) and may be 
best palpated through the rectum. Dermoid cysts usually 
lie in front of the uterus in the vesico-uterine excavation. 

The fluid obtained by tapping has the following char- 
acteristics : 

(a) Microscopic. (See Plate 72, Fig. 5.) 

(6) Chemic : Golden yellow to dark brown (blood) in 
color; specific gravity, from 1010 to 1024 (1005 to 
1055) ; colloid from pseudomucin (metalbumin). The 
demonstration of the latter is important. The albumi- 
nous substances pass through a process analogous to diges- 
tion until they become soluble in water (the older the 
tumor, the more soluble the substance — Eichwald). The 
chemic differentiation of the mucous and albuminous sub- 
stances found together in cystomata is as follows : 



Mucous Series. 

1. The substance of 
the colloid globules 
— transformed cel- 
lular parenchyma. 

2. Mucin. 



3. Colloid substance 
(soluble in water). 

4. Mucopeptone. 



Albuminous Series. 
' (a) Albumin. 
1. i (b) Albuminate 
of soda. 



2. Paralbumin (pro- 
peptone). 

3. Jletalbinnin (pseu- 
domucin) (not sol- 
uble in water). 

4. Albumin -peptone 
(fibrin-peptone). 



Solubility. 

( Boiling +. 

1. -j Acetic acid pre- 

(. cipitates. 



f Boiling -f- . 

2. -J Acetic acid pre- 
( cipitates. 

3. Alcohol precipi- 
tates, mineral acids 
do not. 

4. Precipitated by 
neutral metallic 
salts, potassium 
ferrocyanid, and 
tannin; soluble in 
water. 



DIFFERENTIAL DIAGNOSIS. 219 

The albuminous series is differentiated from the mucous series by 
the fact that the former contains nitrogen and sulphur and is precipi- 
tated by tannin and neutral metallic salts. 

The fluid is boiled, and upon the addition of nitric acid all the 
albumins, as far as and including paralbumin, are precipitated. These, 
together with the corresponding mucins, are removed by filtration. 
Upon the addition of alcohol to the filtrate, the metalbumin is coagu- 
lated and sinks to the bottom in white clouds. If acetic acid alone is 
added to the filtrate, a cloudiness occurs, but no precipitation. Met- 
albumin is distinguished from the corresponding colloid substance by 
its insolubility in water, or by its being precipitated by a new test 
with ferrocyanid of potash. 

The reduction test with 10% cupric sulphate solution (Trommer's 
sugar test) is employed for more exact examinations. 

The chemic differential diagnosis between ascitic transudate and 
peritoneal exudate is given in the explanation of plate 58, 1. 

Parovarian Cysts. — Contents clear as water; specific gravity from 
1002 to 1006; rarely richer than this in albumin; ciliated epithelium 
without other formed elements, such as blood-corpuscles. 

Hydrosalpinx. — Contents serous, mucoid, or gritty; rich in albu- 
min; cholesterin, red and white blood-corpuscles, cylindric epithe- 
lium. 

Hydronephrosis, — Much urea is present, demonstrable by partial 
evaporation, extraction with alcohol, and evaporation ; the residue is 
dissolved in a small amount of water and treated with concentrated 
nitric acid. Rhomboid plates of urea nitrate are formed. Low 
specific gravity; little albumin. 

Echinococcus Cysts. — (Occur in the genitalia in 4% of all cases, espe- 
cially in the uterine submucosa and in Douglas' pouch.) Specific 
gravity from 1007 to 1015; hooklets and scolices; no albumin; much 
NaCl, and especially succinic acid. The latter is demonstrable by 
partial evaporation, dilution with water, and extraction with ether; 
upon evaporation the monoclinic prisms — six-sided plates of succinic 
acid — are obtained, or the watery solution gives a rust-colored floccu- 
lent precipitate with ferric chlorid. 

I. Intrauterine Tumors. 

Differential Diagnosis. — 1. Pregnancy. — Absence of 
the menses, gradual typical increase in size, and, after the 
fifth month, fetal movements, ballotement, and audible car- 
diac sounds. The cervix is livid and soft. Characteristic 
softening of the lower uterine segment (bimanual through 
the rectum). The variable signs of pregnancy and secre- 
tion from the breasts are worthless, as they also occur 
with cystomata. The sound and the trocar are not to be 
used until pregnancy is absolutely excluded. 



220 OVARIAN CYSTOMATA. 



PLATE 72. 

Fig. 1.— Primary Formation of Cysts from a Multilocular 
Glandular Mucoid Cyst of the Ovary. (See also Plates 68-70 
and Figs. 60, 62.) The individual cystic spaces (1) are formed be- 
cause the walls tear, from mucoid degeneration (2, 3), and float about 
in the fluid colloid contents as free papillae (2). (4) Smallest cyst. 
(5) Connective tissue. (Original drawing from a specimen. ) 

Fig. 2. — Papillary Proliferating Cyst of the Ovary. (Orig- 
inal drawing from a specimen from the Munich Frauenklinik. ) (1) 
Broad papilla containing a cyst (2) lined, as is the entire cyst, with 
columnar epithelium (4), with pouchings similar to glands or folds 
(5); (3) cross-section of papillse ; (8) fine dendritic papillae; (6) dense 
connective tissue of the cystic wall; (7) external wavy elastic layer of 
connective tissue. 

Fig. 3. — Necrotic Cyst=wall. Myxomatous degeneration and 
separation of the connective-tissue fibers (2); vascular space (1). 
(Original drawing from a specimen.) 

Fig. 4.— Sediment from the Fluid of an Ovarian Cyst. (1) 
Cholesterin crystals; (2) red blood-corpuscles; (3) granular columnar 
epithelium; (4) fatty granular cell; (5) leukocytes; (6) endothelium. 
(Original drawing. ) 



Retroflexion of a gravid uterus is to be especially con- 
sidered. The chief symptom is ischuria. 

It is to be further remembered that the product may 
have died (chilliness). 

2. Hematomdra, with or without Hematosalpinx. — If 
congenital, the menses have never appeared ; if acquired, 
they have been absent since a definite time. The patulous 
condition of the vagina and uterus is to be demonstrated 
by the sound. 

3. Intramural and Submucous Myomata. — Menorrhagia, 
labor-like pains, slower growth than in cystomata. They 
are dense, and vascular murmurs are usually present ; the 
uterine cavity is elongated. They frequently coexist with 
cvstomata. 



Tab. 72. 




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DIFFERENTIAL DIAGNOSIS. 221 



II. Pedunculated Tumors of the Uterus and Adnexa. 

4- Subserous uterine myomcda present symptoms similar 
to those just mentioned, and, in addition, the cervix moves 
with the tumor, sometimes being forced in the opposite 
direction by leverage. With the exception of cystic fibro- 
mata and edematous tumors, their consistency is greater 
(cystomata may also become hard from extravasation of 
blood after torsion of the pedicle). 

5. Intraligamentous Uterine Myomcda. — Symptoms as in 
3 and 4. They are intimately associated with the uterus, 
and are to be differentiated from intraligamentous cysts 
only by their hardness. 

6. Hydrosalpinx, Hematosalpinx, Pyosalpinx. — Anam- 
nesis, fever, tenderness and pain, lateral situation and 
sausage-shaped or horn-shaped, with constrictions. (Plates 
41, 44, 59, 74.) Tapping. 

7. Parovarian Cysts, — These are round ; they show 
marked fluctuation, and are not nodular, but unilocular. 
They are close to the uterus and have, at most, an insig- 
nificant pedicle. Tapping. 

8. Ovarian Fibromata. — These possess a uniform 
density, a surface covered with small protuberances, and 
are of slower growth. 

III. Tumors of the Pouch of Douglas. 

9. Abdominal Pregnancy. — This is characterized by 
temporary amenorrhea and by pain, and occasionally the 
decidua is cast off. The sac has no pedicle, and portions 
of the fetus may be recognized. 

10. Intraperitoneal Retro-uterine Hematocele. — -Sudden 
origin, with collapse. The fluctuating tumor fills the 
recto-uterine pouch. The vaginal vault is tender. No 
diagnostic incision should be made. (Plate 58.) 

The extraperitoneal peri-uterine hematocele (hematoma) 
leaves Douglas' pouch free and lies to the side of the 
uterus. 



222 OVARIAN CYSTOMATA. 



PLATE 73. 

F IG# i # — Myxosarcoma of the Uterus. (Original drawing from 
a specimen from the Munich Frauenklinik. ) It arises primarily or 
from an unusually rapidly growing fibroma (which has undergone 
degeneration from insufficient nutrition or from infection). (1) Ma- 
lignant ' l giant cells. " ( 2 ) Round-cell proliferation. ( 3 and 4 ) Myx- 
omatous connective tissue ; the fibers are pressed apart. (See also 
Plate 73, 2.) 

Fig. 2.— Spindle=cell Sarcoma of the Uterus. With cyst 
formation (2) ; (1) giant cells abundantly present among the spindle 
cells. (Original drawing from a specimen from the Munich Frauen- 
klinik. ) (See also Plate 87, 2. ) 

By sarcomata we understand tumors of the connective-tissue type 
with an abnormal predominance of the cellular elements (round, 
spindle, giant, and stellate cells). They occur as soft, lobulated 
tumors, which grow rapidly, soon give rise to metastases, and recur 
upon removal. In contrast to epitheliomata, they arise more com- 
monly in early life. They are found in the uropoietic apparatus, in 
the vulva, in the vagina, in the uterus, in the ovaries, and in the 
remaining adnexa. 

They occur in the vulva as round-cell sarcomata, spindle-cell sarco- 
mata, myxosarcomata, and melanosarcomata ; in the vagina (Plate 73) ; 
in the uterus (Plate 87, Fig. 2) ; in the ovary they present a spindle- 
cell type, with or without cyst formation. 

Fig. 3.— Malignant Adenoma Growing through a Cyst=wall. 

(Half diagrammatic original drawing from a specimen from the Munich 
Frauenklinik.) The superficial columnar epithelium (1) grows out 
into an atypically arranged adenomatous mass (6), consisting of cystic 
glandular spaces (7), with columnar epithelium (6)J which is strati- 
fied in various places (8). The interstitial connective tissue (9) is 
scanty. The cyst- wall consists of columnar epithelium (1), dense 
fibrous connective tissue (2), wavy elastic connective tissue (3), with 
thin-walled vascular spaces (4), and the endothelium of the serosa (5). 

Fig. 4;— Angioma of the Urethra. (Original drawing from a 
specimen.) The blood-capillaries (1) consist of endothelial cells 
alone, and lie close together in the connective tissue (2). (See also 
explanation to Plate 51, Fig. 2. ) 



Tab. 73. 



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DIFFERENTIAL DIAGNOSIS. 22$ 

11. Fluid Exudative Peritonitis. — This pursues a febrile 
course, with violent pains, tympanites, and vomiting. 
Diarrhea is often present. The patient is unable to walk. 
The tumor is at first fluctuating or doughy ; later, it is 
nodular and the uterus is immobile. (Plate 17, Fig. 1.) 

12. Parametritic tumors present characteristics similar 
to the foregoing. They are to one side or posterior, and 
above the vaginal vault. Contracted intraligamentous 
abscesses are connected with the margin of the uterus. 
(Plate 59, 1.) 

IS. Pedal tumors are rarer, and are occasionally adher- 
ent to cystomata. They are to be palpated from the rec- 
tum as they are located in its wall. Stenosis is sometimes 
present. It is often impossible to establish the true con- 
dition of affairs ; a cyst may be adherent to the intestine. 

11^.. Tumors of the pelvic bones are immovably connected 
with them, and grow more slowly. It is very important 
that the ovaries should be located, since cysts adherent to 
the pelvis may closely simulate them upon palpation. 

15. Anterior sacral hydromeningocele (a hydromeningo- 
cele of the dura mater between the body and ala of the 
sacrum) is a great rarity. 

IV. Other Abdominal Tumors. 

16. Floating Kidney. — The movable tumor is reniform, 
firm, and somewhat sensitive. The normal renal dullness 
is absent, and in its place a tympanitic percussion-note 
may be obtained. A pelvic pedicle is wanting. 

17. Hydronephrosis. — This will have existed for a long 
time, and grows downward from the lumbar region with- 
out a pelvic pedicle. The intestines are in front of the 
tumor, whereas in ovarian growths they are either behind 
or above. Tapping. 

18. Penal tumors ; Hematomata (Plate 77). — Echino- 
coccus cysts of the kidneys, of the liver, and of the pelvis 
give a hydatid thrill. Tapping. 

19. Splenic Tumor. — This extends to the pelvis from 



224 



OT'ABIAX CYSTOMATA. 





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226 OVARIAN CYST03IATA. 



PLATE 74. 

Figs. 1 and 2.— Bimanual Examination of a Pyosalpinx with 
a Full and with an Empty Rectum. Both bladder and rectum are 
to be emptied before every bimanual examination, as these illustrations 
show how easily deceptive ideas of the form and of the size of tumors 
may be obtained. Py, Pyosalpinx; B, rectum; U, uterus. 

p IG 3.— Bimanual Examination, with Assistance, of the 

Pedicle of an Ovarian Cyst (according to B. S. Schultze). (Orig- 
inal diagrammatic drawing. ) The uterus is drawn downward with 
the bullet-forceps; the cyst is elevated through the abdominal wall; 
palpation is made from below through the rectum. In this way the 
pedicle is made as tense as possible. In the illustration the latter is 
twisted. 

the left side of the abdomen, but has no pelvic pedicle. 
Leukemia. 

20. Tumors of the omentum, subperitoneal hematomata 
(Plate 78), and tubercular and carcinomatous adhesions 
have no pedicle extending into the pelvis. Ascites or a 
tympanitic note may be demonstrated beneath them. The 
ovaries are normal. 

21. Cysts of the pancreas have no pelvic pedicle. 

22. Tumors of the bladder produce characteristic vesical 
disturbances. The urine should be examined for portions 
of tumor tissue. Dilatation of the urethra. They may be 
adherent to cystomata. 

23. Tumors of the abdominal walls and parietal peri- 
toneum are intimately adherent to the skin, and their out- 
lines are strikingly distinct to palpation. During respira- 
tion they move backward and forward with the abdominal 
wall ; intraperitoneal tumors move up and down with the 
diaphragm and disappear with increased tension of the 
abdominal muscles. In all positions of the body the tumor 
holds the same relation to the abdominal parietes. If the 
tumor is flattened by the contraction of the abdominal 
muscles, and can be felt immediately underneath their 



OS 




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TORSION OF PEDICLE. 227 

tense fibers, it springs from the serosa or from the trans- 
verse fascia ; if the tumor becomes more prominent and 
fixed by the abdominal tension, it springs from the 
muscles themselves ; if the tumor remains movable, it is 
situated in the subcutaneous connective tissue. 

A fluctuating tumor in the lower abdomen may be a 
perimetritic or a parametritic abscess, or, if tubercular 
lumbar scoliosis is present, a psoas abscess ; if the tumor 
is right-sided, appendicitis, typhlitis, perityphlitis, and 
an adherent pus tube in the vesico-uterine pouch must be 
considered. 

V. Conditions Simulating Tumors. 

21^. Distended Bladder. 

25. Ascites. (See Plate 58, 1.) 

26. Increased Amount of Fat in the Abdominal Wall. 

27. Meteorism. — General tympany is present ; the geni- 
talia are normal ; localized hardness is absent ; so-called 
" phantom tumors " are to be observed. 

Prognosis. — Ninety per cent, of all cysts larger than a 
man's head are fatal from rupture and peritonitis, from 
suppuration, or from exhaustion. Malignant degeneration 
is always possible. Dermoid cysts suppurate easily or 
undergo carcinomatous degeneration. 

Torsion of the pedicle is dangerous. It produces dis- 
turbances of the circulation with venous thrombosis, 
extravasation of blood, or rupture of the tumor. If the 
nutritional disturbance is gradual, retrograde metamor- 
phoses occur ; if it is rapid, necrosis (Plates 69 and 72) 
and gangrene follow. 

Diagnosis of Sudden Torsion of the Pedicle. — Acute 
increase of pain ; the tumor, often the abdomen also, 
becomes tender, causing the patient to bend forward in 
walking ; reflex nausea ; moderate evening rises of tem- 
perature, with morning remissions. 

Treatment. — (See § 32.) If a cyst is as large as a 
child's head, it must be removed ; pregnancy is no longer 



228 OVARIAN CYST031ATA. 



PLATE 75. 

Figs. 1 and 2. — Two Different Cut Surfaces of a Sarcoma of 
the Ovary. (Original water-color from an operative specimen from 
the Heidelberg surgical clinic. ) 

considered to be a contraindication to^the operation. It 
is also best, however, to remove smaller cysts by ovari- 
otomy, especially if they produce violent pressure phe- 
nomena, severe nervous symptoms, or render the indi- 
vidual unable to work. Since the other ovary likewise 
may easily undergo carcinomatous degeneration, the age 
of the patient, the family history, and the marriage rela- 
tion must be carefully considered in every case, in order 
to determine whether the immediate removal of this organ 
is not also advisable. 

Tapping should be resorted to only when special indi- 
cations are present. These are as follows : When the 
operation is refused ; during delivery ; when marked 
dyspnea or other pressure symptoms are present and 
ovariotomy is contraindicated by malignancy, weak heart 
with edema, etc., profound anemia, pulmonary tubercu- 
losis, nephritis, or other severe incurable constitutional 
diseases. 

The cyst is to be tapped through the abdominal walls or the vagina 
by Bresgen's trocar or Potain's apparatus, the most rigid asepsis being 
observed and the entrance of air being carefully guarded against. 

PLATE 76. 

Fig. 1.— Sarcoma of the Ovary. (Original water-color from an 
operative specimen from the Heidelberg surgical clinic. ) 

Fig. 2. — A Case of Commencing Sarcomatous Degeneration 
of the Ovary. The albuginea is thickened, and small follicular cysts 
maybe seen through the otherwise atrophic germinal layer. (Original 
water-color from an operative specimen from the Heidelberg surgical 
clinic. ) 



iO 



a 
H 




1 




Si 



5 




s 







TREATMENT. 229 

The trocar and elastic tube are to be previously filled with sterile 
water, and the free end of the tube is to be immersed in a receptacle 
containing the same fluid. This prevents the air from being sucked 
in by an accidental falling-back of the tumor; this accident is further 
hindered by sewing the cyst to the abdominal wall, which also renders 
impossible the escape of the fluid into the abdominal cavity. The 
cyst is to be evacuated by placing the patient in an appropriate posi- 
tion and not by manual pressure. The fluid is to be slowly drawn off, 
since a rapid removal is frequently followed by collapse. The punc- 
ture is to be closed by adhesive plaster (in the shape of a Maltese 
cross ) or by an occlusive dressing. 

Ovarian cysts rarely contract after tapping; they usually refill, and 
the patient becomes profoundly exhausted. Extirpation by modern 
aseptic methods has a mortality of only \\ c / c (Fritsch). At the 
Heidelberg Frauenklinik, in 1896, there was only one fatal result in 
sixty celiotomies ( severe anemia and multiple my omata ) ; there was 
not a fatal case from ovariotomy. 



It is not within the scope of this book to go into the 
details of the technic of ovariotomy, but the preparation 
of the patient and the after-treatment, with its complica- 
tions, will now be considered. The clay before the oper- 
ation the patient receives a full bath ; the abdominal walls 
are shaved, scrubbed, and disinfected (soap and brush, 
alcohol and brush, sublimate solution and brush). Dur- 
ing the night a sublimate compress is applied to the lower 
abdomen (Fritsch). Since infectious germs always exist 
in the cutaneous glands and in the deeper layers of the 
epidermis, the disinfection must be repeated immediately 
before the operation, special attention being given to the 
navel, old scars, or other uneven places in the skin. 

For several days preceding the operation the diet should 
be liquid but nutritious (bouillon, eggs, milk, oatmeal- 
water). The bowels must be thoroughly and energetically 
evacuated, care being taken, however, that this is not car- 
ried to excess. Immediately before the operation the 
bladder is to be emptied ; the vulva and vagina are to be 
thoroughly cleansed and tightly packed with iodoform 
gauze in case it is necessary to open the vaginal vault or 
to perform other operations through the vagina. 

Dressing and After=treatment. — Dermatol is to be 



230 OVARIAN CYSTOMATA. 



PLATES 77 AND 78. 

Multiple Extraperitoneal Extravasations of Blood, Espe= 
cially in the Great Omentum. The largest one was connected with 
the atrophic kidney by numerous peritoneal adhesions, and simulated 
a renal tumor. ( Plate 77. ) The different stages of development are 
shown in plate 78 in their natural size. Figures 1 and 2, primary 
extraperitoneal hemorrhages; as the hemorrhage increases a peritoneal 
pedicle is formed ( Fig. 3 ) ; the greater portion of the wall is now in- 
sufficiently nourished, and undergoes necrosis; the capillary vessels 
are seen radiating from the pedicle into the tumor; complete necrosis 
occurs upon torsion of the pedicle. (Fig. 4.) A cross-section shows 
the bloody contents and the thickening of the wall. (Fig. 5. ) (Orig- 
inal water-color from specimens in the* Heidelberg Path. Inst. ) 

dusted upon the line of incision ; this is to be followed by 
iodoform gauze or iodoform collodion, cotton, and an 
abdominal binder. This dressing is not to be changed 
for several days unless it is absolutely necessary. The 
sutures are to be removed on the tenth day ; if vaginal 
sutures suppurate, they are to be removed earlier, and a 
compress saturated with a solution of aluminum acetate x 
is to be applied. 

Immediately after the operation free diaphoresis is to be 
encouraged (the bed is to be previously warmed), partly to 
hasten reaction, partly to prevent abdominal transudation, 
which furnishes a culture-medium for any micro-organisms 
which may have accidentally gained access to the peritoneal 
cavity (Fritsch). 

First day : Allow the patient very little fluid in the form 
of restorative drinks : cold tea especially ; small quantities 
of wine, cognac, or rum and water are exceptionally 
allowable ; bouillon, coffee perhaps, and cracked ice and 
rectal injections of normal saline solution for the thirst. 
The patient must be kept warm. If reaction is tardy, 
rectal injections of alcohol, wine, or ether may be given in 

1 See Therapeutic Table. 



Xi 
a 
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Tab. 78. 




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Lith. Arist. /'■ ReuithoUl. Mi inch en . 



AFTER-TREATMENT. 231 

addition to the foregoing remedies. If signs of internal 
hemorrhage present themselves, the wound is to be 
reopened. 

First week: Liquid nutritious diet. An enema of infu- 
sion of senna 1 is given on the second day to guard against 
the formation of intestinal adhesions (Kehrer). 

From then on two enemata are to be given daily, 
especially if abdominal pain is present. Mild cathartics 
may also be employed. If the urine is not passed spon- 
taneously, the patient is to be carefully catheterized twice 
daily. Dorsal position ; the lateral position (caution ! ) is 
to be allowed only with threatened hypostasis of the lungs. 
Vomiting may occur from swallowed chloroform (cracked 
ice and iced champagne), meteorism, constipation, or peri- 
tonitis. The bed is not to be changed until the beginning 
of the — 

Second week : Easily digested solids ; if the condition of 
the patient is absolutely good, veal, chicken, Zwieback, 
toast, wheat-bread, etc., may be allowed after the fourth 
or fifth day. 

The patient may get up in the third week. 

For meteorism : warm fomentations, oil of peppermint, 
fennel tea, high introduction of the rectal tube ; if com- 
bined with marked vomiting, increased temperature, ten- 
derness, and peritoneal exudate (peritonitis), inunctions 
of blue ointment, and administration of calomel. (See p. 
123 ; § 15.) 

If very severe sudden collapse with anemia occurs (in- 
ternal hemorrhage), the wound should be immediately 
reopened. Severe sudden collapse with dyspnea and 
cyanosis (especially in fibromyomata) indicates pulmonary 
embolism. 

1 The author is in a position to compare the routine treatments of 
two clinics for many years. In the one, the opium treatment, placing 
the intestines at rest, was employed; in the other, the enemata of 
senna infusion were adopted. The latter treatment is, in his opinion, 
undoubtedly the better, especially as the subjective condition of the 
patient more nearly approaches the normal. 



232 OVARIAN CYSTOMATA. 



PLATE 79. 

Fig. 1.— Epithelioma of the Vulva. (Original drawing from a 
specimen from the Munich Frauenklinik.) (Compare with Plate 80, 
Fig. 2.) The epithelioma originates in the squamous epithelium (4). 
Numerous plugs of cells (5) are seen dipping down from the surface 
(4) into the stroma (3) and forming " cell nests," which are sur- 
rounded by connective tissue richly infiltrated with round cells. The 
capillaries are dilated. At the edge of the stroma epitheliomatous 
"pearls" are formed from the cuboid cells of the matrix (1) and 
from the polygonal epithelium which proliferates centrally from them. 
A giant cell is seen among these cells at (2). 

Fig. 2.— Part of an Epitheliomatous Papilloma of the Vag= 
inal Cervix. (Original drawing from a specimen from the Munich 
Frauenklinik.) 1, Epitheliomatous papilla: the central connective 
tissue is infiltrated with round cells and contains thick-walled vessels; 
the squamous epithelial cells are seen at the periphery. 2, Connec- 
tive tissue infiltrated with nests of cancer cells. 3, Extra vasated 
blood. 

Fig. 3— Epitheliomatous " Pearls" from an Ulcer of the 
Cervix. The structure is the same as in figure 1. 1, Cuboid cells 
of the matrix; 2, polygonal cancer epithelium; 3, connective tissue 
infiltrated with round cells and traversed by dilated vessels; 4, 
lymph capillaries. (Original drawing from a specimen from the 
Munich Frauenklinik.) 

Fig. 4. — Dermoid Cyst. (See Plate 45, Fig. 2.) (Original 
drawing from a specimen from the Munich Frauenklinik. ) 1, Super- 
ficial squamous epithelium with connective-tissue papillae; 2, low 
epithelium resting upon an even stroma ; 3, hair, with sebaceous gland 
consisting of cuboid epithelium; 4, cross-section of a hair; 5, muscle- 
fiber; 6, connective tissue. 

Dermoid cysts generally originate in the ovary (very rarely also in 
the vulva). They develop from the same tissue elements as do the 
cystomata, only with this difference : they assume a cutaneous char- 
acter and are made up of all portions of the skin, from the epidermis 
to the subcutaneous connective tissue. There is scarcely a tissue or 
an organ in the body, be it ever so complicated, which may not also 
occasionally appear in these tumors (maxillary bones with teeth, 





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AFTER-TREATJIEXT. 233 

brain -substance, eye, etc.). The cysts are filled with sebaceous mat- 
ter and blond hair. 

These dermoid growths may coexist with ovarian cysts; they may 
also undergo carcinomatous degeneration. With these exceptions 
they are always unilocular; they have thick walls and vary in size 
from that of a man's fist to tumors the size of a man's head. 

Their etiology is uncertain; they may be due to "intraf elation," 
from fission and displacement of the fetal rudiments. 



As the peritonitis subsides the exudate undergoes ab- 
jrption, organization, and encapsulation. (For the treat- 
lent see § 18.) 



CHAPTER III. 

MALIGNANT TUMORS. 

The malignant tumors consist of epitheliomata (squa- 
mous epithelial tumors), malignant adenomata (glandular 
cancers), malignant papillary cysts of the ovary (papillary 
glandular proliferations), sarcomata (round-cell and 
spindle-cell proliferations, with or without mucoid degen- 
eration or deposits of pigment in the intercellular tissue), 
and endotheliomata (proliferations of the endothelium of 
the vessels, or angiosarcomata, since they are a connecting 
link between epitheliomata and the connective-tissue 
tumors). 



\ 36. MALIGNANT TUMORS OF THE VULVA, BLADDER, 
AND VAGINA. 

These occur: 

On the Vulva.— (1) Epithelioma (Plates 80, Fig. 1; 79, Fig. 1); 
(2) fibrous carcinoma (rare); (3) malignant adenoma of the glands of 
Bartholin ; ( 4 ) sarcoma ( see explanation of Plate 73, Fig. 3 ) . 

In the Urethra. — (5) Epithelioma (very rarely primary). 

In the Bladder.— (6) Villous cancer (Plate 88, Fig. 5); (7) diffuse 
scirrhus of the entire wall; (8) multiple nodular carcinoma; (9) sar- 
coma (very rarely primary). 

In the Vagina. — (10) Papillary epithelioma (Plates 79, Fig. 2; 80, 
Fig. 2; 88); (11) flat diffuse carcinomatous infiltration (Plates 80, Fig. 
2; 88); (12) sarcoma (Plate 73, Figs. 2 and 3; rare). 

Symptoms and Diagnosis. — Epithelioma of the vulva: 
pruritus often exists long before the small, flat, reddened 
nodules make the skin uneven. Later the edges are livid 
and dense ; small nodules are observed in the surrounding 
skin. Disintegration soon occurs and there is early met- 
astasis to the inguinal glands. The ulcer has irregular 

234 



VULVA.— BLADDER.— VAGINA. 235 

edges with hard surroundings. The patient is usually 
over forty years of age. 

Sarcoma of the vulva occurs in younger patients, and 
may be congenital ; the tumor has a fibrous structure. 
For the anatomy of sarcoma see explanation of Plate 73, 
figure 2. 

Cancer of the bladder: symptoms as in §31 under 
Bladder. Urethral dilatation is necessary. The tumor 
consists of soft, crumbling, polypoid masses, which are 
readily torn away from the tumor ; these do not consist 
of intact villi, as in a fibrous tumor, but of disintegrated 
shreds of tissue (microscope). These tumors are usually 
secondary ; metastasis occurs early ; embolism is frequent ; 
peritoneal symptoms are observed. 

Epithelioma of the vagina : pruritus is also observed 
here ; irregular hemorrhages. Pain, both during coitus 
and spontaneous. If ulcerated, purulent and offensive 
discharges and casting-off of fetid, crumbling pieces of 
tissue. Vesical disturbances gradually appear, and finally 
fistulous tracts are formed. (See Plate 79.) When a 
vaginal epithelioma is diagnosed, it must be determined 
whether it is not a secondary growth from the cervix. 
(Plate 88.) Papillary epithelioma usually begins anteriorly 
with a broad base (chronic vaginitis). The nodular form 
is usually peri-urethral ; the nodules quickly coalesce and 
soon ulcerate. 

Sarcoma causes analogous disturbances. (See Plate 73.) 
Death follows from venous metastases, septicemia, or hem- 
orrhage. Recurrent fibromata or polyps are to be looked 
upon with suspicion. 

Treatment. — All these tumors must be removed as 
soon as they are diagnosed. This is accomplished with 
the knife and the Paquelin cautery ; the limits of the ex- 
tirpation must lie outside of the infiltrated zone. Glandular 
metastases are not to be neglected. As a prophylactic 
measure at the time of the menopause, every suspicious 
large or weeping warty prominence on the vulva should be 



236 MALIGNANT TUMORS. 



PLATE 80. 



Fig. 1. — Ulcerated Epithelioma of the Left x Labium Majus. 

(Original water-color.) This tumor at first consists of slightly red- 
dened individual flat prominences and nodules. The edge of the 
tumor is very dense and is of a bluish color; the central portion soon 
becomes disintegrated. The tumor creeps along slowly, giving early 
metastases to the inguinal glands. The vagina is usually spared. 
Histologically, the tumor consists of squamous epithelium (Plate 79, 
Fig. 1 ) ; it is very rarely a fibrous carcinoma. 

Fig. 2. — Flat Ulcerating Epithelioma of the Posterior Lip 
of the Os Uteri and of the Posterior Vaginal Vault. (Original 
water-color. ) This tumor has grown from epitheliomatous nodules. 
(See Plate 88, Fig. 1.) 

removed. It is not right first to subject them to prolonged 
cauterizations. 

Urethral carcinoma does not lead to incontinence as long 
as the sphincter remains intact. If the case is inoperable, 
the decomposing urine is to be drawn off as quickly as 
possible and the interior of the bladder disinfected. 

In cancer of the bladder (Plate 88, Fig. 5), if it is a cir- 
cumscribed villous tumor, the affected portion of the vesical 
wall is to be removed ; if it is diffuse, flat, and consists of 
nodular formations, excochleation with the sharp curet. 
Irrigation with solutions of salicylic acid or silver nitrate ; 
if hemorrhage occurs, ice-water irrigations, ice-bag, and 
vaginal tamponade. On the following day the coagula are 
to be removed through a large catheter. 

PLATE 81 

Fig. 1.— Nodular Epithelioma of the Vaginal Cervix. (Orig- 
inal water-color.) 

Fig. 2.— Epitheliomatous Papilloma of the Anterior Lip of 
the Os Uteri. (View of the cervical canal. ) (Original water-color. ) 

1 Translator's Note. — The original reads " right." 










:§ 

I 



« 

^ 




UTERINE CARCINOMA. 237 

\ 37. MALIGNANT TUMORS OF THE UTERUS. 

I. Carcinoma of the Uterus. 

The individual varieties of uterine cancer are : 

1. Epitheliomatous papilloma of the vaginal cervix. (Plates 79, 
Fig. 2; 81; 84, Figs. 1 and 2 (beginning); 85, 1; 88, 1-4; 90, 2.) 

2. Flat epithelioma of the cervix and of the vaginal vault. (Plate 
80, Fig. 2. ) 

3. Epitheliomatous ulcer of the cervix. (Plates 79, Fig. 3; 82; 83; 
85, Fig. 2; 86; 89.) 

4. Xodular epithelioma of the cervix. (Plates 80, Fig. 2; 83.) 

5. Superficial epithelioma of the body of the uterus. (Plate 89, 
Figs. 3 and 4. ) 

6. Glandular cancer, malignant adenoma of the body of the uterus. 
(Plates 30, Fig. 3; 87, Fig. 1.) 

Symptoms. — It is of the utmost importance to diag- 
nose these malignant tumors as early as possible, because 
it is only in the beginning, before metastases have occurred, 
that the opportunity exists for a thorough removal without 
recurrence. 

The initial symptoms in nearly every case are hemor- 
rhages, discharge (first mucoid, then purulent, and finally 
sanious with or without crumbling particles of tissue), and 
pain (sometimes pruritus). Finally, the discharge assumes 
a most offensive character. 

If the hemorrhages and pain are not so pronounced, the 
case is probably one of cancer of the uterine body. 

The irregularity of the hemorrhages at the climacteric 
period easily deceive both the patient and the physician. 
These cases must consequently be watched all the more 
closely. 

The pain is inconstant, of a tearing, boring, or lancinat- 
ing character, and radiates to the sacrum and thighs. In 
corporeal carcinoma the pain is colicky or paroxysmal and 
is associated with the discharge of solid tissue particles 
from the uterine cavity. Other causes for the pain are 
pressure upon nerves, destruction of the uninvolved soft 
parts by the foul cancer discharge, the formation of fistu- 
las, and the subsequent vesical catarrh. 



238 UTERINE CARCINOMA. 



PLATE 82. 
A View of an Epitheliomatous Ulceration of the Mucous 
Membrane of the Cervical Canal. The external os is intact. In 
spite of its apparent insignificance, this case was an inoperable 
one, as the atypical proliferation, as a matter of fact, extended deep 
into the parametritic tissues, involving the bladder wall and fixing the 
uterus. (Original water-color from an actual case. ) 

All varieties of vesical disturbance make their appear- 
ance. Vomiting and headache occur very early, from 
pressure upon the ureters (v. YTinckel), and are to be 
looked upon as uremic in character. The urine is always 
decreased in amount. 

Later, as the wall of the bladder becomes affected, usu- 
ally at the trigonum, with closure of the ureters by a dense 
infiltration, the symptoms assume an unmistakable uremic 
character. Almost complete anuria exists, the patient 
becomes unconscious, edematous, and has convulsions. 
The edema is increased by the firm infiltration of the para- 
metritic tissues, which compresses the pelvic veins and 
produces thromboses. These infiltrations gradually nar- 
row the rectum and cause fecal stasis, hemorrhoids, and 
tenesmus. 

General symptoms occur — cachexia, reflex dyspepsia, 
and disgust for food. Death follows from exhaustion, 
uremia, or peritonitis. 

Diagnosis. — Inspection of the cervix through the 
speculum. (See colored plates.) The tumors bleed easily, 
and are so friable that they tear when seized by tenacula. 

In cervical ulceration it is to be noted that the os uteri 
remains closed and intact, while the cervical canal is 
transformed into a dilated, disintegrated cavity. This is 
demonstrated by the sound, as is also the disintegration of 
the walls of the dilated uterine cavity. These ulcers are 
punched out, with reddened, swollen edges ; they have a 
lardaceous coating and bleed easily. They are found espe- 



Tab. 82. 




Lith.Arist E Retchhold, Mtinchm. 



DIAGNOSIS.— TREATMENT. 239 

cially in the vaginal vault as extensions from the cervix, 
as well as in the cervical canal. (Plate 82.) 

An absolute diagnosis is made by the microscopic ex- 
amination of pieces of tissue, which are either cast off or 
intentionally scraped from the uterine wall. (Regarding 
glandular cancer, see Plate 30, Figs. 2 and 3.) 

An exact anamnesis must always be obtained to avoid 
errors in diagnosis. In this way a decomposing abortion 
or retained placenta may be excluded at the beginning ; 
the microscope would, in addition, reveal chorionic villi 
and decidual tissue. A disintegrating fibromyoma (see 
§ 34, Differential Diagnosis) is recognized by the firm 
consistency of the pieces of tissue removed for diagnosis 
and by their histologic fibrous structure. The rare mul- 
tiple condylomata of the cervix must be considered ; they 
are not yellow, like the epitheliomata, but bluish-red ; they 
have the same etiology as the condylomata of the vulva. 

It is also to be mentioned that certain obstinate inflam- 
mations of the endometrium occurring at the menopause, 
and having the microscopic structure of fungous endome- 
tritis, are often nothing more than the beginnings of gland- 
ular cancers ; in the same manner papillary erosions and 
laceration scars act as predisposing causes of papillary 
epitheliomata. 

Treatment. — The suspected masses, with at least one 
or two centimeters of the surrounding healthy tissues, are 
to be immediately removed by operation. 

As a prophylactic measure endometritis, erosions, lacer- 
ation scars, and ectropion are to receive appropriate and 
early treatment. 

If an epitheliomatous papilloma is certainly limited to 
the cervix (Plates 84, Fig. 2 ; 88, Figs. 2 to 4 ; 90, Fig. 
2), one or both lips of the os and the affected portion 
of the vaginal vault mav be removed. (Plates .80, Fig. 
2 ; 81 ; 84, Fig. 1 ; 85, Fig. 1 ; 88, Fig. 1.) 

If, on the contrary, we have to do with an ulcer of the 
cervix, it seems to me that its removal can be surely 



240 UTERINE CARCINOMA. 



PLATE 83. 

Figs. 1 and 2. — Epitheliomatous Ulcer of the Cervix. 

(Through the speculum and in cross-section; original water-color.) 
(See also Plate 89, Fig. 2. ) The tumor consists of the solitary pri- 
mary nodules and of their ulcerations. Figure 2 shows the nodular 
infiltration of the cervical wall. 



secured only by the total extirpation of the uterus. 
Schroder's supravaginal amputation of the cervix through 
the vagina, even if the ulcer does not reach to the internal 
os, is frequently followed by recurrences in the body of 
the uterus, from which metastases may occur. It may 
not be a question of metastasis at all, as we have speci- 
mens which show that beginning carcinomatous degener- 
ation may simultaneously exist in the body or fundus of 
the uterus and in the cervix. (Plates 82 ; 83 ; 85, Fig. 2 ; 
89, Figs. 1 and 2.) 

Total extirpation may be performed : 

1. Through the vagina (Langenbeck-Czerny) — colpo- 
hysterotomy. 

2. After opening the abdominal cavity (Freund) — celio- 
hysterotomy. 

3. By the sacral method (Hochenegg-Herzfeld-Hegar). 

4. By the parasacral method (Wolfler). 

PLATE 84. 

Fig. 1.— Epitheliomatous Papilloma of the Anterior Lip of 
the Os Uteri and of the Anterior Vaginal Vault. (Original 
water-color.) (See Plates 79, 85, and 88.) The tumor consists of 
uneven bluish masses, which render the os difficult of recognition by 
palpation. This form spreads along the surface. 

Fig. 2.— Beginning Epithelioma of the Cervix. (Original 
water-color from a case of v. Winckel's. ) Small round nodules develop 
at the external os. They are in the cervix, beneath the mucous mem- 
brane, and soon ulcerate. 



■H| 





TREATMENT. 241 

The patients are prepared as usual (full bath, evacuation of the 
bowels by laxatives and enemata, bladder emptied immediately before 
the operation); the vaginal and uterine cavities are to be irrigated 
several times with antiseptic solutions and then wiped out. 

1. Vaginal Extirpation. — The cervix is made accessible by means 
of Simon's duckbill specula (one posterior, one anterior, and two 
lateral retractors), and is drawn down by a stout ligature passed 
through its substance. If the parametritic tissues are infiltrated, the 
uterus is more or less fixed, and a removal of all the diseased tissue is 
out of the question. 

The stout ligature not only aids in drawing down the uterus, but 
at the same time it also closes the external os and prevents the escape 
of the infectious masses of an intra-uterine carcinoma. If the case is one 
of papilloma of the cervix, as much as possible of the carcinomatous 
tissue is to be removed by the knife, scissors, and sharp curet, and 
the remainder is to be destroyed with carbolic acid or Paquelin's 
cautery before the vaginal vault is oxDened. The vagina is to be again 
wiped clean with antiseptics. 

After the removal of the uterus from the ligated adnexa, the wound 
in the vaginal vault is made smaller by several sutures and is drained 
with iodoform gauze. The ligatures left in the adnexa and about the 
parametritic vessels usually come away spontaneously. The patient 
is to be kept in bed for two or three weeks. 

2. Total Extirpation by Celiotomy. — This operation, devised by 
Freund, is still indicated to-day for large dense tumors ( or those com- 
plicated with fibromyomata) that can not be removed through the 
vagina. Bardenheuer's modification is the best: the cervix is cir- 
cumscribed by a vaginal incision; the abdominal cavity is opened, 
the ligaments are tied off on each side in three sections, the uterus is 
removed, and the wound is united by suture. 

3. The sacral and the parasacral methods maybe carried out if ad- 
hesions, parametritic cancer nodules, or a large uterus (it may be 
puerperal) render the median incision ineffectual. 

The inoperable cases demand symptomatic treatment. 

1. For the putrid suppuration : removal of the carcinoma- 
tons masses by means of knife, scissors, curet, and ther- 
mocautery. As an eschar, and later a malignant granu- 
lating surface, is left behind, the wound should be closed 
as far as possible by sutures, which exert a certain restrain- 
ing pressure upon the all-too-rapid proliferation. During 
this excochleation, avoid creating rectal or vesical fistulas. 
Atmocausis is to be employed in such cases. 

As far as caustics are concerned, especially in cases that 
can not be cureted, I wish to mention only carbolic acid 
and formalin. Schroder applied 20 % bromin alcohol for 
16 



242 UTERINE CARCINOMA, 



PLATE 85. 

Fig. 1. — Epitheliomatous Papilloma of Both Lips of the Os. 

The tumor has ulcerated, invaded the deeper tissues, and spread to the 
anterior vaginal vault. (Original water-color.) 

Fig. 2. — Epitheliomatous Ulcer of the Cervix. (Original 
water-color. ) The external os and the cervix are intact ; the lips of 
the os and the cervical wall are, however, markedly thickened by the 
carcinomatous infiltration. The cervical canal is ulcerated and forms 
a crater between the external and the internal os, which is easily 
demonstrable by the sound. The walls contain disintegration cysts 
filled with putrid masses. Solitary cancer nodules are seen in the body 
of the uterus. The neck of the uterus is much enlarged, in contrast 
to the body. 

five minutes by means of cotton tampons. These were 
held in position by tampons saturated in normal saline 
solution. Nitrate of lead (powdered, 30 parts, with 70 
parts lycopodium) is slower in its action — from twelve to 
sixty hours. 

For the fetid odor : potassium permanganate in strong 
solution (dark reddish-brown), or irrigation several times 
daily with 1 ^ or 2 ^ creolin, cresol soap, or lysol. 
Quinin iodid and aristol are to be used as dusting-powders. 

2. For the hemorrhages the following treatment is pallia- 



PLATE 86. 

Fig. 1. — Epithelioma of the Cervix That Has Perforated 
into the Bladder. (Original water-color. ) In spite of the great de- 
struction above it, inspection shows the os uteri to be almost com- 
pletely unchanged. Greenish-gray putrid masses and necrotic shreds 
cover the floor of the carcinomatous ulcer. The uterine wall is infil- 
trated with nests of cancer cells. (See Plate 89, 5. ) 

Fig. 2. — Perforation of an Epithelioma of the Cervix into 
the Bladder and Rectum. (Original water-color from a specimen 
of v. TVinckel's. ) The os uteri has become ulcerated and the process 
extends to the vagina. (See Plate 89, 6. ) 



f 





TREATMENT. 243 

tive : astringent irrigations or vaginal suppositories, vin- 
egar, alum, ferripyrin powder, chloricl of iron ; iodoform 
gauze tamponade, or packing with gauze soaked in solution 
of aluminum acetate or in formalin solution. 

The general nutrition is to be carefully regulated. 
Preference is to be given to a light, easily digestible and 
stimulating diet, with stomachics (compound tincture of 
cinchona), hematogen, hemalbumin, ferratin, wine of iron 
peptonate, and the like. Laxatives and high injections, 
if necessary, with infusion of senna. 

3. For the Lancinating Pains. — The following may be 
used successively as the pains grow more severe : sul- 
phonal, trional, urethan, and chloralamid by the mouth ; 
antipyrin, extracts of hyoscyamin and belladonna, chloral, 
and laudanum by the rectum, later also by the mouth ; 
finally, morphin subcutaneously in gradually increasing 
doses. 

If.. For the vomiting : stomachics, decoctions of condu- 
rango, cracked ice, cold milk (buttermilk), iced champagne, 
cold tea. 

5. For the headache : cold applications, lactophenin, 
phena c et i n, a ntipy rin . 

Since the two latter symptoms are of a uremic nature, 
they are also to be treated by warm baths, hot packs, and 
the induction of profuse sweating. 



II. Sarcoma of the Uterus. 

For anatomy see Plate 73. 

These tumors are as malignant as the carcinomata, if not 
more so. They occur in the uterine body as primary 
growths or as secondary deposits from ovarian sarcomata 
(see Plate 87, 2) ; the patients affected are often in their 
youth. They usually consist of a round-cell proliferation, 
sometimes associated with spindle cells. (Plate 73.) They 
become villous or polypoid, and dilate the os uteri. Met- 
astases take place through the venous system — finally as 



244 UTERINE SARCOMA. 



PLATE 87. 

Fig. 1.— Carcinoma of the Uterine Body. (Original water- 
color from a specimen of v. WinckePs. ) Nodular, soft, easily crum- 
bling, bluish-red masses are seen upon the mucous membrane. They 
also extend into its depths, either as solid plugs of cells from the 
superficial epithelium, or as a malignant adenoma from the glandular 
epithelium. 

Fig. 2. — Sarcoma of the Uterus. (Original water-color from a 
specimen from the Munich Frauenklinik. ) The soft, fibrous masses 
are 'like tinder. They are mucous, muscular, or subperitoneal, and 
may arise from the myxomatous degeneration of a fibroma. (See also 
Plate 73. ) 

pulmonary emboli. Endotheliomata occur very rarely on 
the cervix. 

Symptoms. — The discharge is profuse, mucoid, not 

PLATE 88. 

Fig. 1. — Flat Cervical Epithelioma of Both Lips of the Os 
Uteri Involving Both Vaginal Vaults. There are two varieties of 
epithelioma of the cervix: (1) the superficial form; (2) the epithelio- 
matous papilloma. Both consist of pings of the proliferating squa- 
mous epithelium. (See Plate 79. ) 

Fig. 2. — Epitheliomatous Papilloma of Both Lips of the Os 
Uteri. (See Plate 85, Fig. 1. ) 

Fig. 3. — Polypoid Epitheliomatous Papilloma of the Ante= 
rior Lip of the Os Uteri. 

Fig. 4. — Epitheliomatous Papilloma of the Posterior Lip of 
the Os Uteri Filling the Entire Posterior Vaginal Vault. 

Fig. 5. — Villous Cancer of the Bladder in Its Most Frequent 
Position. (In the region of the ureteral orifices. ) It has infiltrated 
the vesicovaginal septum. It causes cystitis; cancer cells and shreds 
of tissue are found in the urine. 

Fig. 6. — Rectal Carcinoma (Glandular Cancer) Infiltrating 
the Rectovaginal Septum, The tumor undergoes a crater-like dis- 
integration, so that examination reveals two stenoses, between which 
a considerable dilatation is situated. 



_.o_ 






Tab. 88. 




Fig I . 




Fig.£. 




Fig.3: 




Fir/. 4 . 




Fig. 5. 




Fig. 6. 



Lith. AnstF Rsichhold. Munch en . 



SYMPTOMS— DIAGNOSIS.— TREATMENT. 245 

very bloody, and, in contrast to carcinoma, not offensive 
until late in the disease. Pain first appears with the dila- 
tation of the os uteri. Metastases to the lung cause dyspnea 
and cyanosis. Anemia is present if the hemorrhages are 
severe. 

Diagnosis. — Enlargement of the uterus (see Plate 87) 
with or without dilatation of the os uteri. If the os is 
intact, dilate and palpate the uterine cavity ; villous poly- 
poid excrescenses are present. Microscopic examination 
of cureted pieces. If the fibrous character of the tissue 
renders its nature doubtful, look especially for " giant 
cells. " (See Plate 73, Fig. 2.) It is to be remembered 
that afibromyoma may undergo sarcomatous degeneration. 
(See Differential Diagnosis, § 34.) 

Treatment. — If mucous, excochleation ; if the uterus 
is enlarged, total extirpation. If too far advanced, symp- 
tomatic — as in carcinoma. 



I 38. MALIGNANT TUMORS OF THE ADNEXA, ESPE= 
CIALLY OF THE OVARIES. 

I. Carcinoma. 

Carcinoma of the ovary occurs in various forms: (1) Solid papil- 
lary; (2) a form resembling the papillary eystadenomata, but more 
solid: (3) a form resembling the multilocular eystadenomata, but with 
areas of softening; (4) metastases from a uterine carcinoma, diffuse 
nodules in the enlarged ovary (very rare). 

Anatomy. — The ovaries are disposed to carcinomatous 
degeneration, not infrequently at the age of puberty 
(Olshausen). 

Symptoms. — Nonappearance of the menses, ascites 
and peritoneal phenomena, early cachexia, and metastases 
with disturbances of the circulation in the lower extremi- 
ties. Stenosis of the rectum. (See Plate 59, Fig. 4.) 

Diagnosis. — An enlarged, rapidly growing ovary, or 
ascites with a previous pure glandular cystoma. Explor- 
atory incision and demonstration of nodules, and multiple, 



246 MALIGNANT TUMORS OF THE ADNEXA. 



PLATE 89. 

Fig. 1. — Cancer Nodules in the Cervix, Which Has Not Yet 
Ulcerated. The os uteri is closed; the anterior lip is thickened from 
the carcinoma tons infiltration. (See also Plates 80, 82, 83.) 

Fig. 2. — Epitheliomatous Ulcer of the Cervix. The os nteri is 
closed. (See Plate 85.) 

Fig. 3. — Epitheliomatous Ulcer of the Cervix Which Has 
Invaded the Uterine Body. The os nteri is destroyed. 

Fig. 4. — Carcinoma of the Body of the Uterus Which Has 
Perforated into the Bladder. (Plate 86, Fig. 1. ) The os nteri is 
intact. 

Fig. 5. — Epitheliomatous Ulcer of the Cervix Which Has 
Perforated into the Bladder. The fundus of the nterus is intact; 
the os is destroyed. 

Fig. 6. — Epitheliomatous Ulcer of the Cervix Perforating 
into Both Bladder and Rectum. (Plate 86, Fig. 2. ) 

diffuse, papillary, excrescences in and upon the peri- 
toneum. 

Treatment. — Extirpation, if limited to the ovary ; if 
the growth is not so localized, violent pressure symptoms 
demand tapping or the formation of an artificial anus. 

Glandular carcinomata of the tubes are very rarely primary, and, 
as such, are impossible to diagnose. 

PLATE 90. 
Four Tumor=Iike Changes at the External Os. 

Fig. 1. — Fungous Endometritis and Ectropion. (See Plates 
30, 31, 56. ) Cystic dilated glands in the cervical mucosa. 

Fig. 2 —Epitheliomatous Papilloma of Both Lips of the Os. 
(See Plates 81, 84, 85.) 

Fig. 3. — Ovules of Naboth in a Mucous Polyp, Visible at the 
Os Uteri. (See Plates 29, 56. ) 

Fig. 4. — Fibroid Polyp Separating the Lips of the Os Uteri, 
(See Plate 60, Fig. 2. ) 



Tab. 89. 




Iig.l. 




Fi<f.3. 





Fig. 4% 




Fig. 5. 



Fig. 6. 



LitJi. AnstE Reidihoid, Mindvm . 



Tab. 90. 




Tit/ J. 




Fig.J. 




Fia.2. 




Fig. 4-. 

Lilh . Aast F. Reichhald. Miinche-n. 



SARCOMA. 247 



II. Sarcoma. 

These are visually spinclle-cell tumors in early life, combined with 
deposits of round cells and degenerations of a myxomatous or carcino- 
matous character. They grow slowly, and their diagnosis and treat- 
ment are the same as those of ovarian fibromata. (See ^33 and 35. ) 
Sarcomata also occur in the ligaments. 

Endothelioma^ ( angiosarcoma^ •) may grow to a considerable size 
and show a decidedly malignant character. They have a cavernous 
structure; the tissue is usually myxomatous. 

The treatment is generally hopeless, as total removal is usually 
fruitless, even when carried out at the first appearance of symptoms. 



THERAPEUTIC TABLE. 



1. Absorbents. — Sapo medicatus, potassium iodid, tinct. iodi, iodin 

glycerin, ichthyol, hot vaginal douches, mud-baths, brine- 
baths, hot sand-baths. 
Acids : 

2. Acetic Acid (Pyroligneous Acid). — 1 : 3 or concentrated. To be 

applied through the speculum (with 3 to 4% carbolic acid) every 
two or three days for weeks and months; erosions; cervical 
catarrhs. 

3. Boric Acid.--2 to 3%. In cystitis, urethritis ; 2 to 4 injections 

daily. 

4. Boric Acid Vaselin.— 5 : 20, for pruritus. 

5. Carbolic Acid. — J to 2%, in vaginitis, endometritis. 2 to 5%, 

in vulvitis. 3 to 5% or concentrated, to wipe out the uterine 
cavity, multiple recurrent polyps, fistulas. 

6. Carbolic Acid.— 2%. Subcutaneously, J to 2 syringefuls in lu- 

pus, erysipelas. 

7. Carbolic Acid Glycerin. — 2 to 4%, endometritis, metritis. 

8. Carbolic Acid Intoxication.— Small doses of opium, morphin, 

ice, milk, soluble sulphates. 

9. Chromic Acid.— 25 to 33%, as a caustic for condylomata, 

10. Chromic Acid. — 33%, in fistulas, endometritis (every week). 

11. Fuming Nitric Acid. — As a caustic in lupus, fistulas, endome- 

tritis, one drop upon cotton every four to five days. It acts 
most promptly when immediately followed by the application 
of liquefied carbolic acid. 

12. Salicylic Acid.— 1 to 5 : 1000, in pruritis, vaginitis, cystitis. 

1.0 to 5.0 (gr. xv to gr. lxxv) salicylic acid powder are dissolved 
in alcohol, and added to one liter of lukewarm water (irrigator) ; 
it is not caustic. 

Salicylic Acid Vaselin (Lanolin, Mollin). — 1 : 300, for pruritus. 

13. Tannic Acid. — 0.3 (gr. v), intra-uterine pencil for endometritis. 

(See Intra-uterine Pencils. ) 

14. Tannic Acid Vaginal Suppositories.— 0.4 (gr. vj) with 3.0 

(gr. xlv) cacao-butter in blenorrhea, 
249 



250 THERAPEUTIC TABLE. 

15. Aloes Extract. — Ext. rhei comp., aa 3.0 (gr. xlv). Ft. in pil. 

No. xxx, two pills daily. Laxative, emmenagog. 

16. Althea Decoction. — Injection for vaginitis, acute endometritis, 

acnte myometritis. 

17. Alum in Intrauterine Pencils. — 0.3 (gr. v), 4 cm. long, 0.2 to 

0.4 cm. thick, with gnm arabic and glycerin, in endometritis. 

18. Alum Solution. — 1 to 3 to 6%, as injection or npon tampons in 

vaginitis, vaginal inversion. Iodoform gauze is saturated with 
the solution, and renewed every three hours in acute vaginal 
gonorrhea. 

19. Alum Vaselin (Lanolin, Mollin). — 2 to 4 :50, in pelvitis, vagin- 

itis, vaginal inversion. 

20. Aluminum Acetate Solution. — 10 to 20%, astringent vaginal 

injection. 2 to 5%, intra-uterine application. 

21. Antipyrin. — 0.5 to 1.0 (gr. viij-xv), in pill, every two hours (6.0 

— 3iss — pro die), for menstrual molimina, dysmenorrhea, pain, 
fever. 

22. Antipyrin. — 2.0 (gr. xxx), in solution, as an enema. Also used 

subcutaneously, 1:2; the syringe must be carefully cleaned after 
each injection to prevent the precipitation of antipyrin crystals. 

23. Antispasmodics. — (See Antipyrin, Chloral, Chloroform, Mor- 

phin, Opium, Ext. Yiburn. Prunifol. Fid.) 

24. Applications and Fomentations. — " Priessnitz, " for paralysis 

of the vesical sphincter, peritoneal irritation, acute corporeal 
endometritis, oophoritis. 

Brine. — In myoma ta, chronic parametritis, perimetritis, me- 
tritis, and oophoritis. 
Hot Water. — In menorrhagia, dysmenorrhea, combined with 

hot alcohol. 
Lead-water. — (See Same.) 

25. Argent. Nitrat. — 2% solution, in endometritis, ulcerations of 

the vaginal cervix, urethritis; to be applied or injected (every 
week); or 0.2 to 0.5 : 1000 to be injected from 4 to 6 times 
daily. 

26. Argent. Nitrat.— 1 to 2 to 6 : 1000, in cystitis. 

27. Argent. Nitrat. — 5 to 10 to 20% or solid stick, in pruritus, 

vaginitis, fistulas; applied every week. 

28. Argentamin. — Specific for older cases of gonorrhea: 1 to 2%, 

intra-uterine; 5%, in the vagina. 

29. Argonin. — Specific for gonorrhea: 3 to 5%, intra-uterine; 2%, 

vesical irrigation; 5 to 10%, vaginal irrigation. 

30. Astringents. — Alum, aluminum acetate solutions, cupric sul- 

phate, decoctions of oak-bark, formalin, glycerin, lead-water, 
tannin. 

31. Bathing Resorts. — Mud-baths (absorbent), Teplitz, Franzens- 

bad, Kissingen, Elster and Mattoni's mixture (5 liters to the 



THERAPEUTIC TABLE. 251 

bath) in metritis, parametritis, and perimetritis, chronic oophor- 
itis, hematocele. 

Brine-baths. — Kreuznach, Tolz, Xauheirn, Ki'sen, Ocynhausen. 
Hall (upper Austria), Heilbronn, or artificially produced 
by adding from 10 to 20 pounds of lye or sea-salt to the 
warm bath. Applicable in myomata. scrofula, vulvitis, 
metritis, chronic parametritis, and perimetritis (one-half to 
one and one-half hours in duration, followed by one hour's 
rest). 

For Anemia: Briickenau, Triburg, Elster, Franzenshad, Pyr- 
mont, Schlangenbad, Schwalbach, St. Moritz, Wildbad. 

Hot Sand-baths. — Blasewitz near Dresden, Ki'stritz near Gera. 
Applicable for same affections as mud-baths. May be 
replaced by thermaphore. 

Iodin Baths. — Kreuznach, Tblz, Hall, in scrofula. 

Sea-baths. — In nocturnal enuresis, scrofulous vulvitis, menor- 
rhagia. 

For Vesical and Renal Disease: Carlsbad, Wildungen (0.5 
(gr. viij) sodium salicylate with 0.015 (gr. \ i morphin to J 
of a liter, in cystitis ) , Xeuenahr, Assmannshausen, Ober- 
salzbrunn, Vichy, for menorrhagia from nephritis. 

32. Baths.— Warm baths, 95° to 100° F. (one-quarter to one-half 

hour), in paralysis of the vesical sphincter, uremia (carcinoma- 
tous), oophoritis, acute endometritis, chronic metritis, and 
subinvolution. 

Foot-baths (100° F.), with 1 to 3 tablespoonfuls of salt or 
mustard once or twice daily in oligorrhea, amenorrhea, 
anemic dysmenorrhea. 
Sitz-baths (90° to 100° F.). with wheat bran ( I to 1 pound), 
decoctions of oak-bark (7 to 10 fo), one and a half to two 
hours, in pruritus, urethritis. 
Sitz-baths, with tannin or alum [2% ). sea-salt or lye (1 pound 
to 2 bucketfuls of water), as before, in dysmenorrhea, 
amenorrhea, urethritis, pruritis. parametritis, and perime- 
tritis (ten to twenty minutes in the beginning). 

33. Belladonna Extract. — As rectal or vaginal suppository 0.02 

(gr. J) with 3.0 (gr. xlv) cacao-butter, in rectal and vesical 
tenesmus, dysmenorrhea, endometritis, and myometritis, neu- 
roses of the uterus and vagina. 

34. Belladonna Tinct. — 20 drops t. i. d. (with potassium brornid, 

0.3 (gr. v), in nocturnal enuresis. 

35. Belladonna = vaseiin (Lanolin, Mollin). — 1 to 2:50, in pru- 

ritus. 

36. Bismuth Subnitrate. — Intra-uterine pencils (0.2, gr. iij), in en- 

dometritis. 

37. Bismuth Subnitrate Solution. — 2 to 3j£, astringent intra- 

uterine application. 

38. Bismuth Subnitrate Ointment. — 10 &, in eczema, herpes. 

39. Bismuth Talcum. — Dusting-powder for profuse secretion. 



252 THERAPEUTIC TABLE. 

40. Bromin Alcohol. — 20%, hemostatic injection in carcinoma. 

41. Byrolin=boric Acid — LanoIin=glycerin. — Good salve for the 

hands. 

42. Caffein Citrate. — 0.1 (gr. iss) (with lactophenin, sacchar. alb., 

aa 0.5, gr. vij), for hemicrania. 

43. Caffein Sodium Benzoate.— 0.2 (gr. iij), t. i. d., in migraine. 

44. Calomel. — 0.25 (gr. iv) (with sacchar. alb., 0.5, gr. viij) several 

times daily, or 0.5 (gr. viij) at one dose, as a laxative, in acute 
peritonitis, parametritis, and metritis. To be followed by from 
15 to 20 drops tinct. opii; later, 0.05 to 0.1 (gr. f to iss). 

45. Camphor. — 1.0 (gr. xv), ol. amygd. dnlc, 9.0 ( ^ij), subcutane- 

ously in collapse. 

46. Camphor, Monobromate.— 0.1 to 0.3 (gr. iss to v) with sacchar. 

alb., 0.5 (gr. viij), three times daily in hysteric conditions of ir- 
ritability. 

47. Carlsbad Salts. — 1 to 3 teaspoonfuls on rising, in a glass of luke- 

warm water, as a laxative. 

48. Cascara Sagrada. — Ext. fid., syr. zingiberis, aquae, aa 10.0 

( giiss), a teaspoonful twice daily, as a laxative. 

49. Catheter, Permanent. — 15 to 30 cm. long, 0.6 to 0.7 cm. thick; 

left in position for three days ; it is to be well sterilized ! 

50. Catheterization. — Before every operation, after perineoplasty, 

in paralysis of the vesical sphincter, incontinence of reten- 
tion. 

51. Caustics. — (See Fuming Nitric Acid; Argent. Nitratis, 2 to 20% ; 

Carbolic Acid, 3%, cone; Chromic Acid, 33%; Zinc Chlorid, 5 
to 10 to 50 % ; Vienna Paste ; Solution of Mercurous Nitrate ; 
Caustic Potash; Sublimate, 1 : 1000; Formalin, cone.) The 
vagina is to be thoroughly irrigated after cauterizing the 
uterus. 

52. Caustic Potash —Fistulas, lupus. 

53. Caustic Potash. — 1 : 300, aq., in severe cases of intertrigo. 

54. Chloral. — By the rectum, 1 to 2 : 15 (with potassium bromid, 

aa), in rectal and vesical tenesmus, dysmenorrhea, carcinoma. 

55. Chloral in Rectal or Vaginal Suppositories. — 0.5 (gr. viij) 

with 3.0 (gr. xlv) cacao-butter, for vesical and intestinal tenes- 
mus, dysmenorrhea, uterine and vaginal neuroses, carcinoma. 

56. Chloral Solution. — 5 : 100 (with syr. aurant. cort., 25), to be 

taken for the same affections as above. 

Chloral Solution, — (With syr. aurant. cort., aa), 15 : 175 aq. ; 
one teaspoonful 3 or 4 times daily, in nocturnal enuresis. 
It may be combined with potassium bromid. 

57. Chlorin Water. — (and aq. dest., aa 50.0 (giss) with 1.0 (gr. 

xv ) acid, hydrochlor. ) one tablespoonful every two hours in 
meteorism, peritonitis, diarrhea. 



THERAPEUTIC TABLE. 253 

5?. Chloroform Narcosis. — Chloroform, 3: sulphuric ether, 1; ab- 
solute alcohol, 1 (Billroth). Chloroform -J- ether (1:2) = 
Yieuua mixture. 

59. Chloroform and 01. Hyoscyami, aa 10.0 (giiss). — Inunction in 

pruritus; upon tampons for the pain from carcinoma, peri- 
metritis and parametritis, oophoritis. 

60. Cocain Hydrochlor.— 5 to 10 # solution or ointment as a local 

anesthetic, in pruritis (alternating with 10 to 20 r r argent, ni- 
trat. ), vaginismus, uterine and vaginal neuroses, dysmenorrhea. 
Cocain Hydrochlor. — \ to 1 : 1000, as injection, in cystitis. 
Cocain Hydrochlor. — 0.01 to 0.2'/ in 0.2 V Nad solution for 

Schleich's infiltration anesthesia. 
Cocain Hydrochlor. — In rectal or vaginal suppositories : 0.1 
(gr. issj to 3.0 (gr. xlv) cacao-butter, in vesical and rectal 
tenesmus, carcinoma. 

61. Colocynth. Ext.— 0.005 to 0.02 (gr. T ^ to J), as a drastic 

cathartic. 

62. Condurango Decoction. — 12 : 175, in carcinomatous dyspepsia. 

63. Cornutin Citrate.— 0.003 to 0.005 (gr. oV to T K), in pill, twice 

daily, in metrorrhagia. 

64. Cupric Aluminat. — 1.0 to 5.0 : 1 liter of water, in endometritis. 

65. Cupric Sulphate. — J to 2% injection or upon tampons, in metror- 

rhagia: 1 : 1000, in endometritis. 

66. Cupric Sulphate Vaselin or Zinc Sulphate Vaselin. — 2 to 

3 to 5 : 50 to 75, on tampons, in metrorrhagia. 

67. Dermatol, as a dusting-powder after plastic operations. 

68. Diaphoretics. — Ammonium chlorid solution (5 : 200), liq. 

amnion, acetat. (1 to 2 teaspoonfuls in elderflower or chamo- 
mile tea ) . 

69. Diet in Anemia. — (See \ 3, under 7, Treatment.) 

70. Digitalis Inf. — 2 : 180, syrupi 20, one teaspoonful every two 

hours (with potassium nitrate 10.0 — giiss), in menorrhagia 
from cardiac disease. 

71. Disinfection of the Hands. — (See \ 34. under Treatment.) In 

office practice the hands must be scrubbed with alcohol and 
1 : 2000 sublimate, especially if they have come into contact 
with discharges. Instruments (specula, sounds) are to be well 
boiled each time they are used. 

72. Diuretics. — Potassium nitrate, urotropin. (See under Digitalis 

in Pelvic Peritonitis. ) 

73. Douches, Hot. — ( See Vaginal Injections. ) 

74. Dry Cups. — In oligomenorrhea, dysmenorrhea. 

75. Emollients. — Linseed decoctions, oatmeal water, althea decoction, 

starch. 



254 THERAPEUTIC TABLE. 

76. Enemata for Hemorrhage. — 0.6 ft warm NaCl solution (2 liters 

or more) ; alcohol, wine. 

77. Enemata of Oil. — In intestinal and vesical tenesmus. (See 

Tinct. Opii, Emollients, and Injections, Kectal.) 

78. Enemata (Purgative). — J to 1| liters of lukewarm mucilaginous 

or oily fluid, or of water with or without salt, soap, glycerin, or 
senna (5.0 — gr. lxxv — to the cup). 

79. Ergotin. — (See Secale Cornutum.) 

2.0 (gss) with aq. dest. 8.0. ( 3 i j ) and acid, carbolic, fid. 
gtt. j, one syringeful daily (three to six times a week); 0.2 
(gr. iij), in menorrhagia, metrorrhagia, myomatosis. 

80. Ergotin.— 2.5 (gr. xxxviij) with aq. dest, 15.0 (3 iij) and acid. 

salicyl. 0.05 (gr. f); 1 to 2 syringefuls = 0.15 to 0.3 (gr. ij- 
ivss ) , as in above affections. 



81. Ferric Chlorid Solution. — 20 to 50% or concentrated, applied 

upon cotton to the interior of the uterus by means of the 
aluminum sound; or, upon tampons or injected, in multiple 
recurrent sessile polypi, menorrhagia, carcinoma, Werlhof's dis- 
ease, myomata. 

82. Ferric Chlorid Solution.— 1 : 800, injected into the bladder in 

hematuria — ferripyrin is better. 

83. Ferripyrin. — In powder or solution, 1 : 5, as a hemostatic. 

84. Formalin (35% formaldehyd solution). — 1 : 2 to 3 parts of 

water, 1 tablespoonf ul to a liter of water, as a vaginal and intra- 
uterine irrigation. Undiluted as a caustic agent. 

85. Frangula Cortex. — Add 1 tablespoonful to 3 cups of water, and 

evaporate to 2 cups; or — 

86. Frangula Decoctions. — 25.0 ( 55 viss) : 180.0 (f 3 vj ) with sodium 

salicylate 5.0 (gr. lxxv) and sodium sulphate 20.0 (,^v). A 
wineglass of this mixture is given morning and evening as a 
laxative. The fluid extract is given in doses of from 20 to 40 
drops. 

87. Gelatin Injections. — Intra-uterine, as a hemostatic. 

88. Hemostatics. — Ferripyrin, ferric chlorid solution, aluminum 

acetate solution, gelatin emulsion. 

Iodoform gauze tampon ; galvanocautery, Pacquelin's cautery, 
actual cautery, atmocausis (in operations for carcinoma and 
myoma); bromin alcohol (carcinoma). 

89. Hydrarg., Ung. — 1.0 to 8.0 (gr. xv to gij) pro die, with equal 

part of vaselin, inunctions, every two hours for a week, in peri- 
tonitis. 

90. Hydrastis Canad. Ext. Fid. — 15 to 25 drops, four times daily, 

for months, in menorrhagia (especially if ovarian). 



THERAPEUTIC TABLE. 255 

91. Hydrastinin Hydrochlor. — 0.05 (gr. f) in pill, three times 

daily; or 10% solution, J to 2 syringefuls( subcutaneous )pro die. 

92. Hyoscyami, Oleum. — As inunction. (See Chloroform. ) 

93. Hyoscyami Ext. — 1.5 (gr. xxiij) with aq. amygd. am. 150.0 

(f gv), 15 drops, four times daily, in uterine and vaginal neu- 
roses, vesical and intestinal tenesmus, dysmenorrhea. 

Hyoscyamus Injections. — 15 : 1000, in vaginitis, dysmenorrhea. 

94. Hysteria. — Asafetida; ext. cannabis indica; lactophenin, 0.5 to 

1.0 (gr. vij to xv ) ; salophen, 1.0 (gr. xv); salipyrin, 1.0 (gr. 
xv ); phenacetin, 0.5 to 1.0 (gr. vij to xv); antipyrin, 0.5 to 
1.0 (gr. vij to xv), also by the rectum; monobromated camphor; 
castoreum ; chloral ; chloroform ; belladonna ; cocain ; hyos- 
cyamus ; potassium bromid ; morphin ; opium ; nor. chamo- 
millse ; fol. menth. pip. ; valerian. 

95. Ice=bag. — In acute oophoritis, peritonitis, parametritis, metritis, 

hematocele, erysipelas, uremia (carcinomatous). 

96. Ice, Cracked. — In vomiting. 

97. Ichthyol. — For the exanthemata seen with amenorrhea. 

98. Ichthyol. — 10% solution in water or glycerin, in vulvitis, pru- 

ritus, parametritis, hematocele. 

99. Ichthyol or Ammonium Sulpho=ichthyoIate Vaselin (Lan- 

olin, Mollin, Glycerin). — 10%, in chronic perimetritis, para- 
metritis, oophoritis, vulvitis, hematocele; 10% with green soap, 
upon the abdomen for peritoneal exudate. 

100. Ichthyol in Intrauterine Pencils. — 0.2 (gr. iij), in endo- 

metritis. 

101. Intrauterine Pencils. — With gum arabic and glycerin (4 cm. 

long, 0.2 to 0.4 cm. thick). (See Alum, Bismuth Subnitrate, 
Iodoform (90%) ; Itrol ; Protargol, Ferric Chlorid Solution, 
Tannin, Zinc Oxid, Zinc Chlorid.) Iodoform may be added 
to them all. 

102. Injections.— Into the Bladder (82° to 88° F.), one cup of oat- 

meal water with 15 to 25 drops of laudanum, in vesical spasm. 
Into the bladder in cystitis : \ to 1 liter, 1 to 3 times daily, 
90° to 95° F. (See Argent. Nitrat., Boric Acid, Cocain, Lime- 
water, Saline Solution, Tannin. ) 

Into the Vagina.— Hot (115° to 130° F.), several liters 2 to 
3 times daily, or every two hours in menorrhagia, metror- 
rhagia, myomatosis (for the hemorrhage and as an absorb- 
ent) ; to soften the cervix (in dilatation), in chronic in- 
durated parametritis and perimetritis, chronic oophoritis, 
chronic metritis (during the menses also). They are also 
used when the uterus is infantile, or when it is under- 
going involution. Into the vagina : 82° to 88° F., several 
times daily ; astringents, antiseptics (carbolic acid, lysol, 
potassium permanganate, salicylic acid, sublimate), or 
emollients in beginning metritis. 






256 THERAPEUTIC TABLE. 

Vaginal injections of brine in chronic metritis are best given 
in the full or sitz-bath (5 to 8 liters, 111° to 118° F. ). 

Into the Uterus. — By means of Braun's syringe (drop by 
drop), the two-way catheter; or permanent irrigation by 
means of an elastic catheter, which is held in the uterine 
cavity by a rubber cross-piece. 

Rectal Injections. — (See Chloral, Glycerin, Narcotics, Saline 
Solution, and also Enemata. ) 

103. lodin Glycerin.— 10 : 200, upon tampons, for above affections. 

104. Iodin, Tincture. — Applied to the abdomen, cervix, and vaginal 

vault in corporeal carcinoma, chronic metritis, parametritis, 
perimetritis, and oophoritis. 

105. Iodoform Emulsion, or Iodoform Glycerin.— 10%, in cor- 

poreal carcinoma, endometritis. 

Iodoform Vaselin (Lanolin, Mollin). — 10 to 20%, in vulvi- 
tis, pruritus, oophoritis, parametritis, and perimetritis 
(upon tampons). 

106. Iodoform Gauze, — 10 to 20%, intra-uterine tamponade (for 

twenty-four hours), vaginal tamponade (at first, for six hours ; 
later, from twelve to twenty-four hours), in menorrhagia, 
metrorrhagia, hemorrhages from myomata and carcinomata. 
It is also used to dilate the cervix and in endometritis. 

107. Iodoform Intrauterine Pencils. — 90%, 4 cm. long, 0.2 to 

0.4 cm. thick in acute (puerperal) and chronic endometritis. 
In puerperal endometritis they are to be made 6 cm. long and 
0.4 to 0.6 cm. wide; in inflammations of the vulva and vagina 
in children, they are to be made 5 to 8 cm. long. 

108. Ipecac. — 1.0 (gr. xv) every ten minutes, until vomiting is pro- 

duced. Dover's powder, 0.3 (gr. v), several times daily, in 
dysmenorrhea, dyspepsia. 

109. Itrol. — Excellent dusting-powder for wounds and ulcers ; 1 : 4000 

to 5000 for intra-uterine and vaginal irrigation. It is also 
used as a bougie (3% to 10%) and as a salve (3% to 10%) in 
sepsis (instead of blue ointment). 

110. Krameriae Ext. — 4 : 50, upon tampons, in vaginitis ; it is not 

painfully astringent. It is also used in intestinal catarrh. 

111. Lactophenin. — 0.5 to 1.0 (gr. viij to gr. xv), several times 

daily (with 0.1 — gr. iss— caffein), in neuralgia. 

112. Laminaria. — As intra-uterine tamponade, in metrorrhagia, men- 

orrhagia, to dilate the cervix. They are to be previously care- 
fully disinfected for fourteen days in 5% carbolic acid solution, 
10% iodoform-ether, or 1% corrosive sublimate alcohol. They 
are left in situ twenty-four hours. 

113. Largin. — Specific for gonorrhea ; used like protargol, (See p. 

99.) 



THERAPEUTIC TABLE. 257 

114. Lassar's Paste = Sulph. prec. 50.0 (|iss) with /3-naphthol 

10.0 ( 3 iiss) and lanolin, saponis viridis, aa 25.0 ( 3 viss) . This 
is to be rubbed into a smooth paste. It is applied for acne. 

115. Laxatives (in the Order of Their Efficiency). — Enemata 

(see the same), senna infusion by the rectum ; calcined mag- 
nesia, with or without sulphur ; citrate of magnesia ; compound 
licorice powder ; castor oil ; decoctions of frangula ; wine of 
cascara sagrada : calomel ; .tamarind (Grillon) ; Carlsbad salts ; 
tincture of cascara sagrada ; various waters, such as Kissingen, 
Friedrichshall, Carlsbad, etc. ; powdered rhubarb with aloes ; 
infusion of senna ; compound extract of colocynth by the mouth. 
Dietetic : Fruit ( boiled ) , kefir, whey, buttermilk, in chronic 
perimetritis, dysmenorrhea, oophoritis, metritis, and para- 
metritis. 

116. Lead Acetate. — One teaspoonful to one cup of water == lead- 

water (2 to 5 teaspoonfuls to a liter of lukewarm water), in 
pruritus, vulvitis, vaginitis, erysipelas. 

117. Lime= water. — Used in full strength, for irrigation in cystitis; 

or 25.0 in 500.0 milk internally. 

118. Linseed Decoctions. — In vaginitis, cystitis, acute endometri- 

tis, and metritis. 

119. Magnesia, Calcined.— TO to 2.0 (gr. xv to gr. xxx), 1 to 3 

times daily, as a laxative. 

120. Massage. — In oligomenorrhea, infantile uterus, chronic para- 

metritis and perimetritis, ovarian adhesions. 

121. Menthol Spirit. — b% in pruritus of the vulva, urticaria, and 

pruriginous exanthemata the result of amenorrhea. 

122. Mercuric Chlorid. — 1 : 2000, intra-uterine injection, in mul- 

tiple recurring uterine polypi, endometritis; 1 : 5000, in ure- 
thritis. 

123. Mercuric Chlorid.— 1 to 2 : 1000, in vulvitis, pruritus. 

124. Mercuric Chlorid.— \ to 1 : 1000, in vaginitis. 

125. Mercurous Nitrate.— Caustic for catarrh of the cervix. 

126. Morphin Hydrochlorate.— 0.2 to 10.0 (gr. iij, to f 3 iiss) aq. 

dest, \ to J to 1 syringeful hypodermically = 0.005 to 0.01 
to 0.02 (gr. ^3 to i to i) morphin hydrochlorate, in vesical 
spasm, carcinoma. 

127. Morphin Hydrochlorate (Powder).— 0.01 (gr. \) with sacch. 

alb. 0.5 (gr. viij), in menstrual molimina, dysmenorrhea, 
uterine neuralgia, vesical spasm, and as a hypnotic in car- 
cinoma. 

128. Morphin Suppositories (Rectal or Vaginal).— 0.02 (gr.i) 

with 2.5 (gr. xxxviij), cacao-butter, for same affections as the 
preceding. 

129. Morphin Vaseljn (Lanolin, Mollin).— 1.0 to 2.0 (gr. xv to gr. 

xxx) : 50.0 ( 5iss) in pruritus. 
17 



258 THERAPEUTIC TABLE, 

130. Narcotics (in the Order of Their Efficiency). — Hyoscyainus 

(with chloroform) as an injection; ext. belladonna, in rectal or 
vaginal suppositories; cocain, to be administered in the same 
manner; laudanum, by the rectum; chloral (— potassium 
bromid), by the rectum; antipyrin. by the mouth or rectum; 
morphin, by the mouth, by the rectum, or hypodermically. 
Hypnotics: Sulphonal, trional, potassium bromid, codein, 
chloral, morphin. 

131. Nosophen. — Antiseptic and desiccating dusting-powder for 

wounds. 



132. Oak=bark Decoctions.— 10 to 20 : 250, in vaginal inversion, 

vaginitis. 

133. Oatmeal Water. — (See under Injections into the Bladder in 

Cystitis; and under Injections into the Vagina in Vaginitis, 
Acute Endometritis, and Myometritis. ) 

134. Obesity Cures. — Banting, Oertel, Epstein. Mendelsohn; used 

when the panniculus adiposus is excessively developed — a 
cause of menorrhagia. 

135. Oleum Ricini. — 2 to 3 capsules, one tablespoonful several times 

daily. 

136. Oophorin. — For menstrual molimina; after removal of the 

ovaries. 

137. Opium. — Laudanum, 15 to 25 drops, by the rectum or upon vag- 

inal tampons in menstrual molimina. dysmenorrhea, oophor- 
itis, metritis, parametritis, perimetritis, carcinoma, hemato- 
cele, peritonitis. 

Opium: Extract of opium 0.2 (gr. iij) with emuls. amygd. 
dulc. 150.0 (f§v), one tablespoonful every two hours 
(mixture only keeps a day!), in carcinoma, intestinal 
catarrh, acute metritis, pelvic peritonitis. 



138. Phenacetin. — 0.5 to 1.0 (gr. viij to gr. xv) t. i. d., for neuralgia. 

139. Potassium Bromid. — In powder (1.0 — gr. xv — once or twice 

daily) or solution (15 : 175, 2 to 4 tablespoonfuls daily), in 
nocturnal enuresis, uterine neuralgia, dysmenorrhea, oophori- 
tis, hysteria, pruritus. 

140. Potassium Carbonate Solution. — In folliculitis of the vulva ; 

1 c /c solution for boiling instruments. 

141. Potassium Iodid. — In vaginal suppositories, 0.2 to 0.5 (gr. iij 

to gr. viij)., with 3.0 (gr. xlv) cacao-butter, in parametritis, 
perimetritis, metritis, uterine and vaginal inversion, oophoritis, 
hematocele. 

142. Potassium Iodid=glycerin. — 10 to 15 : 200, upon tampons 

(may add 15 to 20 drops of laudanum), for the affections just 
mentioned above. 



THERAPEUTIC TABLE. 259 

143. Potassium Iodid=vaselin (Lanolin, Mollin). — 3 to 10% in 

pruritis, vaginismus, acute (puerperal ) metritis, and para- 
metritis. 

144. Potassium Permanganate. — Dark cherry-red solution, as an 

irrigation fluid in foul carcinomata. Given as an emmenagog, 
in pill form (0.5 — gr. viij — in a pill, 2 or 3 pills thrice daily). 

145. Protargol. — 0.5 to 2.5 (or even o}%, intra-uterine irrigation; 

5%, vaginal irrigation; 1 to 2.5%, vesical irrigation. Protar- 
gol with glycerin or salve, 5 to 10% intra-uterine (or as a 
bougie), in urethritis. Used in vaginal tamponade ., 7/ is a 
specific for gonorrhea (Xeisser). 

146. Quinin, Compound Tincture.— 20 drops to a half-teaspoonful, 

thrice daily, in anemia, uremia, dyspepsia. 

147. Quinin=iodin. — Dusting-powder, in foul carcinomata. 

148. Rhubarb, Infusion of Root.— 5.0 to 15.0 : 180.0 (gr. lxxv to 

f^ivif^vj) with sulphate of sodium 10.0 (gr. iiss) and 
elgeosacch. menth. piperit.. 5.0 (gr. lxxv), 2 tablespoonfuls 
every two hours as a laxative. 

149. Rhubarb, Powdered Root. — Used as a laxative. 



150. Sagrada, Wine. — J teaspoonful. as a laxative. 

151. Saline Infusion.— 0.6$ . XaCl solution, h to 1 liter (sometimes 

more), intravenous or subcutaneous injections. 

152. Saline Solution. — 5 fir, in cystitis, especially after injections of 

silver nitrate. 

153. Salol. — 1.0 to 2.0 (gr. xv to xxx), 3 or 4 times daily, in cystitis. 

154. Santonin.— Troches or pills, 0.025 to 0.05 to 0.1 (gr. f to f to 

iss ) , 3 times daily, with laxatives to prevent xanthuria ; as an 
emmenagog and anthelmintic. 

155. Secale Cornut., Aqueous Extract. — 15.0 : 175.0 ( Jjiv : g vss) 

with dilute sulphuric acid 2.5 (gr. xxx viij) and tract, cinna- 
momi 15.0 (giv); 1 tablespoonful every fifteen minutes, for 
acute hemorrhage. 

156. Secale Cornut., Extract. — With pulv. secale cornut., aa 2.0 

(gr. xxx). Ft. inpil. Xo. xxx — 1 pill every two or three hours, 
in conditions mentioned above. 

157. Secale Cornut., Ext. Aqueous. — 2 to 4 :180( ^ssto 7. j :f £vj) 

aquae with syr. cinnamomi 30.0 (f^j); 1 tablespoonful every 
two hours, in conditions mentioned above and in paralysis of 
the vesical sphincter. 

158. Secale Cornut. Pulv. — In vesical or uterine hemorrhage, in 

metritis (chronic hyperemia), and after reduction of an in- 
verted uterus. 



260 THERAPEUTIC TABLE. 

159. Sennas Fol., Infusum.— 2 to 4 teaspoonfuls (with 1 teaspoonful 

of fennel) to 1 cup of water, as a laxative. 

160. Sinapisms. — Mustard plasters and analogous applications; can- 

tharidal plasters; or two parts of cantharides, dissolved in sul- 
phuric ether, to one part of a solution of gutta percha in 
chloroform, to be applied to the cervix ! Tincture of iodin is 
also applied to the cervix. It is painted upon the abdomen in 
dysmenorrhea, and upon the thigh in amenorrhea. 

161. Sodium Salicylate. — With sacch., aa 0.5 (gr. viij); 1 powder 

every two hours, or in solution 0.5 : 150.0 (gr. viij : f § v), in 
neuroses, cystitis, erythemata. 

162. Strychnin.— 0.005 to 0.0075 to 0.01 (gr. T \ to i to |) subcuta- 

neously, in vesical paralysis. 

163. Stypticin.— 0.05 (gr. f ) (6 to 8 tablets daily), or 1 : 20 aq. cin- 

namomi (30 drops 5 times daily), or 1 or 2 syringef uls of a 10 % 
solution subcutaneously. 

164. Sulphonal.— 1.0, as a somnifacient. 

165. Sulphur. — 2 teaspoonfuls daily ; precipitated sulphur, powdered 

rhubarb root, compound licorice powder, aa 7.5 (3ij), as a 
laxative. 

166. Suppositories (Rectal). — 2.5 to 3.0 (gr. xxxviij to xlv) cacao- 

butter. (See Morphin, 0.01 to 0.02 (gr. J to J); Ext, Bella- 
donna, 0.01 to 0.02 (gr. i to J); Chloral, 0.5 (gr. viij); Cocain 
Hydrochlorate, 0.1 (gr. iss).) 

167. Suppositories (Vaginal). — 2.5 to 3.0 (gr. xxxviij to xlv) cacao- 

butter. (See Morphin, 0.02 (gr. J); Ext. Bellad., 0.02 to 
0.03 (gr. J to J); Chloral, 0.5 (gr. viij); Cocain Hydrochlor- 
ate, 0.1 (gr. iss); Potassium Iodid, 0.2 (gr. iij); Tannic Acid, 
0.4 (gr. vj).) 

168. Tamarind Decoction.— 8.0 to 50.0:100.0 to 300.0 ( 3 ij to 

^ iss : f ^iiiss to f §x) aquae at one dose, as a laxative. It is 
also administered in the form of tamarind paste (Grillon). 

169. Tampons. — Glycerin (in vaginal inversion), vaselin, lanolin, or 

mollin with tannin, alum, ichthyol. potassium iodid. chloroform 
with oil of hyoscyamus, cupric sulphate, zinc chlorid or sul- 
phate. 

170. Tannin Solution.— 0.5 to 1.0 : 100.0 (gr. viij togr. xv : f giiiss), 

in cystitis. 

171. Tannin Solution. — 2 to 4%, in vaginitis, vaginal inversion, 

vulvitis. 

172. Tannin Vaselin (Glycerin, Lanolin, Mollin).— 2 to 4 : 50.0 (^ss 

t° Z] ' §i ss )> for the above-mentioned affections. 

173. Trional. — 0.5 (gr. viij), in powder, as a somnifacient. 

174. Ung. Hydrarg. Ammoniati. — For pruritus. 



THERAPEUTIC TABLE. 261 

175. Ung. Zinci Oxidi. — For eczema, herpes. 

176. Ung. Zinci Oxidi. — With amyli aa 50.0 ( giss) and acid, salicyl. 

3.0 (gr. xlv) and vaselin (lanolin, mollin), 100.0 ( Jiiiss), for 
pruritus, wounds. 

177. Urotropin. — 0.5 (gr. viij), 3 times daily, as a diuretic. 

178. Viburnum Prunifol., Ext. Fid.— 1.0 to 4.0 (gr. xv to ^j) 

several times daily, as an antispasmodic in dysmenorrhea, 
threatened abortion ; 1 teaspoonful may be given several times 
daily for one or two weeks. 

179. Washing with Cool Water. — For nocturnal enuresis. 

180. Weir Mitchell Rest=cure. — For nervous anemic patients. 

181. Zinc Chlorid. — h% intra-uterine pencil held in position by a 

tampon, for endometritis (three days rest in bed). 

182. Zinc Chlorid. — 10 to 50^ solution, for intra-uterine application 

(once a week) after dilatation of* the cervix in endometritis; 
5 to 10$ injection, for multiple recurrent sessile polypi. 

183. Zinc Chlorid. — \ to 1% injection or upon tampons in vaginitis, 

vaginal inversion. 

184. Zinc Oxid Intrauterine Pencils. — 0.3 (gr. v), in endometritis. 

185. Zinc Oxid. — 2 : 40 pulv. amyli, for intertrigo. 



NDEX 



A. 

Abdominal pregnancy, 221 
Absence of entire genital tract, 19 
of nterus and adnexa, 18 
of vagina, 29 
Acne in amenorrhea, 39, 41 
Adenomyomata, 193 
Adnexa, benign tumors of, 199 
diagnosis, 200 
symptoms, 200 
treatment, 201 
malignant tumors of, 245 
diagnosis, 245 
symptoms, 245 
treatment, 246 
Alexander's operation, 88 
Amenorrhea, 39 
physiologic, 40 
symptomatic, 39 
treatment, 41 
Angiosarcoma ta, 234 
Anomalies of formation, fetal, 17 
hyperplastic, 29 
infantile, 35 
of menstruation, 38 
Anteflexion, infantile, 36 

puerile, 36 
Anterior sacral hvdromeningo- 

cele, 223 
Anteversion and anteflexion, 76 
diagnosis, 76 
etiology, 76 
treatment, 78 
Anus perinealis, 27 
Aplasia, 17 
Arrested development, 35 



Ascites, 178, 227 

Ascitic fluid, characteristics of, 178 

Atmocausis, 115 

Atresia ani, 22 

vaginalis, 22, 27, 29 
vestibularis, 27 
hymenalis, 25, 27 
unilateral, of duplicate geni- 
talia, 26, 27 
urethra?, 22 
vulva\ '22 
Atresias, congenital, 22 

traumatic, 155, 163 
Azoospermism, 47 



B. 

Bartholinitis, 93, 96, 99 
Biers constriction, 100 
Bladder, atrophy of, 142 

benign tumors of, 188 

carcinoma of, 235, 236 

catarrh of, 140 

cysts of, 187 

distended, 227 

drainage of, 147 

fibromata, fibromyomata, 187 

hypertrophy of, 142 

malignant tumors of, 235 

papillomata of, 186, 188 
diagnosis, 189 
prognosis, 189 
treatment, 189 

polyps, 187 

senile, 142 

tuberculosis of, 137, 139 



263 






264 



INDEX. 



Braun's syringe, 197 

Broad ligament, cysts of, 199 
fibromyomata, 199 
fibromyxomata, 199 
lipomata, 199 

Bnboes, 139 

Bullet-forceps, 83 



C. 

Castration, 209 
Celiosalpingectomy, 126 
Cervical canal, diameter of, 37 

length of, 59 
Cervicitis, acute, 101 

chronic, 101 
diagnosis, 105 
symptoms, 104 
treatment, 106 

purulent, 101 
Cervix, atresia of, 27 

catarrh of, 101 

dilatation of, 37, 109, 163 

tears of, 161 
treatment, 161 
Chancre, hard, 139 

soft, 139 
Chancroidal bubo, 139 
Charcot's arch, 153 
Chrobak's extraperitoneal 

method, 210 
Clitoris, duplication of, 49 

fissa, 23 

hvpertrophy of, 49 
Cloaca, 26 
Coccygodynia, 154 

treatment, 154 
Colpeurynter, 56 
Colpitis crouposa, 117 

diphtheritica, 117 

exfoliativa, 44 

gonorrhoeica, 94, 97 

ulcerosa adhsesiva, 151 

vetularum, 151 
Colpocleisis, 172 
Colpocystotomy, 183 
Colpohyperplasia cystica, 187 
Colpomyotomy, 208 
Colpoperineauxesis, 68 
Colpoperineoplasty, 68 



Colpoperineorrhaphy, 68 
Colporrhaphy, anterior, 68 

posterior, 68 
Condylomata^ acuminate, 99, 100 

flat, 139 
Curetment, 110, 111 
Cystitis, anatomy, 140 

diagnosis, 141 

diphtheritica, 141, 142 

etiology, 141, 142 

sequels, 143 

symptoms, 141 

treatment, 146 
Cystocele, 53 

Cystoscope, operative, 144 
Cystoscopy, 144 



D. 

Decidua menstrualis, 43, 44 

vera graviditatis, 44 
Deciduoma, 190 
Defects of uterus, 18 

of vagina, 22 
Dermatitis simplex, 149 
Descensus uteri, 57, 60 
Diagnosis, differential, of ante- 
uterine and retro-uterine tu- 
mors, 224, 225 
Dilatation of cervix, 37, 109, 163 
Displacements of tubes and ova- 
ries, 75 

of uterus, 74 
Distended bladder, 227 
Douglas' pouch, turners of, 221, 

224, 225 
Duplication by a septum, 31 

of cervix, 32 

of clitoris, 49 

of entire genital tract, 29 

of nymphse, 49 

of organs, 29 

of uterine appendages, 30 

of uterus, 30 
Dysmenorrhea, congestive, 42 

etiology, 42 

in infantile anteflexion, 36 

in intramural myomata, 42 

inflammatory, 42 

membranacea, 43 



INDEX. 



265 



Dysmennorrhea, obstructive, 42 
reflex, 42 
treatment, 43 



Echinococcus cysts, 219 
Ectopia vesicae, 167 
Ectropion, 104, 107 

differential diagnosis, 105 
Elephantiasis vulvae, 152, 187 
Elevatio uteri, 72 
diagnosis, 72 
treatment, 72 
Elongatio colli, 61 
Emboli after operations for myo- 

mata, 202, 205 
Endometritis acuta, 118 
chronica, 100 
diagnosis, 105 
symptoms, 104 
treatment, 106 
corporis uteri, 107 
symptoms, 108 
treatment, 109 
dissecans, 108 
exfoliativa, 44, 108 
from stenosis, 38 
fungosa, 108 
glandularis, 107 
haemorrhagica, 108 
interstitialis, 108 
polyposa, 108, 185 
post abortum, 108 
yeast cultures, introduction of, 
110 
Endothelioma, 234, 244, 247 
Enemata, Hegar's, 133, 135 
Enterocolpocele, 50 
Enuresis nocturna, 146 
Episioplasty, 159 
Epispadias, feminine, 23, 29 
Epithelioma, 185, 234 
Erosion, differential diagnosis, 
105 
follicular, 105 
papillary, 105 

differential diagnosis from 
cancer, 234 
simple, 105 



Eversio vesicae, 167 
Evolutio praecox, 39 
Exanthemata, periodic, 149 

vulvar, 149 
Excisions, wedge-shaped, 107, 116 
Exf oliatio mucosae menstrualis, 43 

diagnosis, 44 
Exstrophia vesicae, 167 
Extra-uterine pregnancy, 176 
Exudates, parametritic, 135 

perimetritic, 132 



Facies ovarica, 200 
Fallopian tube, cysts of, 199 

fibromata, fibromvomata, 199 
hydatids of, 199 
lipomata of, 199 
papillary proliferations of, 
199 
Faradization for cervical stenosis, 

37 
Ferripyrin, 46 

Fibroma of ovary, 208, 211, 221 
Fibromvomata, cervical, 199 

"delivery" of, 196 

diagnosis^ 196, 206 

enuncleation of, 209 

etiology, 191 

histoid, 192 

indications for operation, 209 

intercorporeal, 194 

intraligamentous, 194 

intramural, 194 

organoid, 193 

polypoid submucous, 194 
subserous, 194 

sarcomatous changes in, 207 

sequels of, 202 

submucous, 194 

subserous, 194 

symptoms, 195, 205 

torsion of pedicle, 202 

treatment, 197, 208 
Fibrosarcoma, 207 
Fissura vesicae inferior, 167 

superior, 167 
Fistula, cauterizations for, 173 

congenital, 22 






266 



IXDEX. 



Fistula, ileo-uretero vesical, 168 
ileo vaginal, 168, 173 
ileovesical, 168 
intestinal, 168 
operations for, 172 
rectohymenalis, 23 
recto-ureterovesical, 168 
rectovaginal, 168, 171 
rectovesical, 168 
rectovestibularis, 23 
ureterocervical, 167 
urethrovaginal, 165, 170 
urinary, 165 

after-treatment, 173 
diagnosis, 171 
symptoms, 170 
treatment, 172 
vesico-abdominal, 167 
vesicocervical, 166 
vesicocervico vaginal. 165, 166 
vesieo-umbilicalis, 167 
vesico-ureterovaginal, 166, 171 
vesicovaginal, 165, 170 
Floating kidney, 223 
Folliculitis vulvae, 150 
Foreign bodies in bladder, 180 
treatment, 180 
in genital tract, 180 
treatment, 180 
Fritsch's operation, 159 
Furunculosis vulvae, 149 



G. 
Garrulitas vulvae, 158 
Gartner's ducts, 200 
Genital canal, duplications of, 29 
tuberculosis, diagnosis, 137 
histology, 136 
prognosis, 138 
symptoms, 137 
treatment, 138 
Gonococci, 94, 97 
Gonorrhea, 93 
diagnosis, 97 
latent, 95 
symptoms, 96 
treatment, 97 
Gonorrheal endometritis, 95 
mixed infection, 96 



Gonorrheal peritonitis, 96 

pyosalpinx, 95 

urethritis, 99 
Gummata, 140 



H. 

Hegar's castration. 211 

enemata, 133, 135 

funnel, 99, 147 

operations, 116, 159, 211 
Hematocele, intraperitoneal retro- 
uterine. 176, 221, 224 
diagnosis, 177 
etiology, 176 
prognosis, 179 
symptoms, 177 
treatment. 179 
Hematocolpos, 25 
Hematoma, extraperitoneal, 175 

vaginae, 26 

vulvae, 26, 175 
Hematometra. 25, 163, 164, 220 
Hematosalpinx, 25, 220 
Hermaphroditism, 20 
Hernia, diagnosis, 48 

inguinalis labialis, 48 

treatment, 49 

vaginalis labialis, 48 
Hot sand-baths, 135 
Hydatids, formation of, 199 
Hydrocolpocele, 50 

treatment, 52 
Hvdromeningocele sacralis ante- 
rior. 223 
Hvdrometra. 163 
Hydronephrosis, 219, 223 
Hydrops folliculorum, 211 
Hydrosalpinx, 124 
Hymen bifenestratus, 33 

septus, 33 
Hvperin volution, puerperal, 40, 

134 
Hyperplasias, 29 
Hypertrophy of bladder, 142 
Hypoplasia. 17 

Hypospadias, feminine, 22, 27. 29 
Hysteric symptom-complex, 153 
I Hysterocleisis, 172 
J Hysterotrachelorraphy, 162 



INDEX. 



267 



Ileovaginal preternatural anus, 

169 
Impotentia coeundi, 46 
Impressio fundi uteri, 54, 55 
Incontinence, fecal, 157 
of retention, 145 
urinary, 145 
vulvar, 155, 158 
Inflammation, etiology, 93 
glandular, 92 
interstitial, 92 
terminations, 93 
Intermenstrual pain, 109 
Intertrigo, 158 
Intestinal fistula, 168 
Inversion of anterior vaginal wall, 
53 
treatment, 53 
of posterior vaginal wall, 52 

treatment, 53 
of uterus, complete, 55 
diagnosis, 55 
etiology, 54 
partial, 54 
symptoms, 55 
treatment, 55 
of vagina, 50 
diagnosis, 52 
treatment, 52 
Ischuria paradoxa, 145 



K. 

Kehrer's operations, 37, 57, 116 
Kustner's operation, 57 
urethral funnel, 99, 147 



L. 

Lacerations, 154, 157, 158 
Laminaria, 109 
Lochiometra, 163 
Lupus vulvae, 137 



M. 
Mackenrodt's operation, 172 
Martin's operation, 68, 89 



Massage, 90 

Masturbation, 42, 93, 101, 151 

Menorrhagia, etiology, 45 

treatment, 45 
Menstrualis, decidua, 43, 44 
exfoliatio mucosae, 43, 44 
Menstruation, disturbances of, 39 
physiologic, 38 
vicarious, 41 
Metalbumin, 218 
Meteorism, 227 
Method of Schultze, 216, 226 
Metritis, acute, 118 
diagnosis, 120 
symptoms, 119 
treatment, 123 
chronic, 111 
diagnosis, 113 
etiology, 113 
prognosis, 113 
symptoms, 113 
treatment. 114 
Metrorrhagia, 195, 205 
Molimina menstrualia, 20 
Mollusca, 195 

Morphinism as a cause of amenor- 
rhea, 39, 40 
Miillerian ducts, 17, 25, 26, 32 
Myomata, cervical, 207 
intraligamentous, 207, 221 
vascular bruit in, 208 
Myometritis, 109, 120 
Myomotomy, 209 
Myxedema, peritoneal, 213 
Myxofibroma ovarii, 198 
Myxosarcoma, 204, 222 

N. 

Nervous symptoms in retroflexion, 

81 
Neuralgia in laceration scars, 158 

in uterine and ovarian tumors, 
195, 198, 201 

lumbo-abdominal, 154 

uteri, 42 
Neuritis in carcinoma, 237 
Neuroses in amenorrhea, 39 

of the vagina, 143, 150 

periodic, 41 



268 



INDEX. 



Xew growths, etiology of. 184 
Xymphse, duplication of, 49 



O. 

Oligocvstic degeneration, 128 
Oligomenorrhea, etiology, 39 

treatment. 40 
Oophoritis, acute, 119, 222 
chronic, 126 
diagnosis, 128 
etiology, 126 
symptoms, 123 
treatment, 129 
Oophorosalpingitis. 127 
Operation. Alexander's, 88 
Fritsclrs. 159 
Hegar's, 116, 159 
Kehrer's, 37, 57, 116 
Kustner's, 57 
Mackenrodt's. 172 
Martin's. 6-. 89 
Martin's (A.), 116 
Schroder's, 116 
Simon's, 116, 159 
Sims', 37. 116, 164 
Skutsch's, 89 
v. AVinckel's. 163 
Ovarian cystomata. anatomy, 211 
character of contents, 218 
definition, 211 
diagnosis. 216, 219 
histology, 211 
multilocular, 211 
prognosis, 227 
sequels, 213 
symptoms, 213 
tapping, 228 
torsion of pedicle, 227 
treatment, 227 
unilocular, 211 
Ovarica, facies, 200 
Ovarie, 154 

Ovariocolpocele. 50. 75 
Ovary, abscess of, 127 
atrophy of. 127 
dermoid cyst of. 213 
fibroma of, 199. 221 
fibromyomata of, 199, 221 



Ovary, multilocular glandular 
mucoid cysts of, 211 
oligocvstic degeneration of. 128 
papillarv proliferative cysts of, 

213, 216 
presence of third. 34 
racemose cysts of. 213 
unilocular cysts of. 211 

Ovulation. 38 

Ovules of Xaboth, 108 



P. 

Pancreas, cysts of. 226 
Papillary vulvitis. 149 
Paracolpitis, acute. 117 

chronic. 134 
Paralbumin, 218 
Parametritis, acute, 120, 123 
chronic. 134 
atrophic, 134 
symptoms, 135 
treatment. 135 
diagnosis. 134 
etiology. 134 
symptoms. 134 
treatment, 135 
exudates of, 121, 223 
Paraproctitis, 117 
Paroophoritic adenomvomata, 
195, 199 
cvsts. 200 
Parovarian cvsts. 200, 201, 219, 

221 
Pean-Hegar's extraperitoneal 

method, 210 
Pelvic peritonitis, diagnosis, 132 
etiology, 131 
prognosis, 131 
symptoms, 131 
treatment, 132 
Pelvis fissa, 23 
Pericystitis, 131 
Perimetritis, chronic. 131 

exudates of. 132 
Perimetro-oophoritis, 96 
Perimetrosalpingitis. 96 

serosa, 131 
Perineal defects, congenital. 29 
lacerations, etiology of, 156 



INDEX. 



269 



Perineal lacerations, operations 
for, 159 
sequels, 157 
symptoms, 157 
treatment, 159 
perforation, 156 
Perineoplasty, 159 
Perineorrhaphy, 159, 160 
Periproctitis, 131 
Peritoneal myxedema, 213 
Peritonitis, acute, 119, 231 
exudativa saccata, 119 
gonorrheal, 133 
pelvic, 131, 132 
sacculated, 233 
tubercular, 133, 138 
Pessaries, application of, 84, 89 
care of, 87 
disadvantages of, 87 
intra-uterine, 37, 38 
lever-, 71, 84 
Pessary, Breisky's, 71 
Hewitt's, 71 
Hodge's, 71, 84, 85 
Mayer's ring, 70, 84 
Schultze's 8-shaped, 71, 84, So 
sledge-, of B. S. Schultze, 71 

reversed application of, 90 
Z'angerle-Martin stem-, 71 
Phlebectasia, vulvar, 151 
Phlegmone vaginae, 117 

vulvae, 117, 149 
Placenta, retention of, 239 
Playfair's aluminum sound, 195, 

199 
Pregnancy, abdominal, 221 

diagnosis of, 219 
Prolapse, vaginal and uterine, 57 
complete, 57 
development, 60 
diagnosis, 63 
etiology, 62 
partial, 57 
reposition, 71 
symptoms, 61 
treatment, 64-74 
Propeptone, 218 
Pruritis vulvas, 149, 150 
Pseudohermaphroditism, 20 
Pseudomucin, 218 



Pulmonary emboli, 202, 205 
Pyocolpocele, 50, 75 

treatment, 52 
Pyocolpometra, 29 
Pyometra, 163 
Pyo-oophorosalpinx, 127 
Pyosalpinx, 125, 126 

R. 

Rectal injections, Hegar's, 133, 

135 
Rectocele, 52 
Reposition of prolapsed uterus, 

71 
Retained catheter, 147, 174 
Retention of urine, 145 
Retrorixatio colli, 89 
Retroflexion, puerile, 79 
Retroversion and retroflexion, 
congenital, 79 
diagnosis, 82 
etiology, 79 
reposition, 90 
symptoms, 81 
treatment, 83 
Rhagades, 157 
Rose's procedure, 181 
Round ligament, adenomvomata 
of, 199 
fibromyomata of, 199 
Rudimentary cornua of the uter- 
us, 26 



S. 

Salpingitis, acute catarrhal paren- 
chymatous, 125 
purulent catarrhal and inter- 
stitial, 125 
chronic catarrhal parenchyma- 
tous, 124 
interstitial, 126 
diagnosis, 125 
nodosa, 199 
symptoms, 125 
treatment, 125 
Sarcoma of uterus, 222, 243 
of vagina, 235 
of vulva, 235 



270 



IXDEX. 



Schroder's intraperitoneal meth- 
od, 210 
Sectio alta, 183 
Senna infusion, 231 
Sepsis, 117 
Simon's operation, 116, 159 

specula, 32, 147 
Sims' operation, 37, 116, 164 

position, 32 
Singultus hystericus, 153 
Sinus urogenitalis, 27 
Skene's glands, 31 
Stem-pessary in anteflexion, 37 
Stenosis, congenital, of cervix, 36 

hymenalis, 38 

traumatic, 162 
anatomy, 163 
diagnosis, 163 
etiology, 163 
symptoms, 163 
treatment, 163 

vulvovaginalis, 38 
Sterility, etiology. 46 

examination of patient, 47 

following gonorrhea, 96 

in anteflexion, 77 

in infantile anteflexion, 36 

in uterine prolapse, 62 

treatment, 47 

with bilateral ovarian cyst, 
200 
Subinvolution as a cause of metri- 
tis, 93 

as a cause of prolapse, 62 
Suprapubic cystotomy, 183 
Supravaginal amputation, 209 
Suspensio uteri, 89 

T. 

Tamponade of pouch of Douglas, 

138 
Tapping, 228 
Tenesmus, rectal, 53, 78 

vesical, 146 
Tertiary syphilides, 140 
Torsion of uterus, pathologic, 91 

physiologic, 91 
Transmigratio seminis, 22 
Traumatic effusions, 175 



Tube. See Fallopian tube. 
Tubercular peritonitis, 133, 138 

tumors of omentum, 226 
Tuberculosis, genital, 136, 137 

peritoneal, 139 

vesical, 137, 139 
Tumors, benign, 186 

conditions simulating, 227 

etiology of, 184 

intraligamentous, 199 

malignant, 234 

of abdominal walls, 226 

of bladder, 186, 187, 188, 235 

of Fallopian tube, 199 

of kidney, 223 

of ligaments, 199 

of omentum, 226 

of ovary, 199 

of parietal peritoneum, 226 

of pelvic bones, 223 

of pouch of Douglas, 221, 224 

of rectum, 223 

of tube, 199 

U. 

Ulcer, cervical, 120 

vaginal, 120 

vulvar, 120 
Ulcus durum, 139 

gangrenosum, 139 

molle, 139 
Uremia, 142 

in carcinoma, 238 
Ureters, angulation of. 60, 86 
Urethra, carcinoma of, 236 

caruncle of, 186 

condylomata of. 186 

cystic myxo- adenomata, 187 

fibromata of, 187 

fibromyomata of, 187 

polyps of, 187 

tumors of, 187 
treatment, 188 
Urethritis gonorrhceica, 99 
Urinary fistula. 165 
Urina spastica, 143 
Urine, retention of, 145 
Urogenital septum, 27 

sinus, 27 



IXDEX. 



271 



Uterine asthma, 41 
cavity, size of, 59 
Uterus, auiputatio supravaginalis, 

209 
antepositio, 73 
ante versions and anteflexions, 

76-79 
benign tumors of, 189 
bicornis, 30 

septus, 32, 33 
carcinoma of, 237 
cavity of, 59 

diadelphus (didelphys), 29 
duplex, 29 
fibromyomata of, 192 
totalis, 35 
infantilis, 32, 35, 38 
lateropositio, 73 
ligaments of, 59 
malignant tumors of, 237, 243 
diagnosis, 238, 245 
symptoms, 237 
treatment, 239, 241, 245 
membranaceus, 35, 36 
mucous polyps of, 190 
diagnosis, 190 
symptoms, 190 
treatment, 191 
myxosarcoma of, 222 
normal length of, 36, 59 

relations of, 59 

situation of, 57 

width of, 59 
pathologic positions, 73 
retropositio, 73 
retroversions and retroflexions, 

79-91 
sarcoma of, 222, 243 
supports of, 59 
total extirpation of, 209 
tuberculosis of, 137 
unicornis, 20 

V. 

Vagina, atresia of, 22, 27, 29 
cysts of, 187 

treatment of, 187 
duplex, 29 
epitheliomata of, 235 



Vagina, fibromata of, 187 
fibromyomata of, 187 
inversion of, 50, 52, 53 
lacerations of, 160 
symptoms, 161 
treatment, 161 
myxofibroma, 187 
neuroses of, 143, 150 
phlegmon of, 117 
sarcoma of, 235 
septa, 33 
subsepta, 33 
tuberculosis of, 137, 138 
ulcers of, 120 
Vaginismus, 38, 150 
etiology, 151 
treatment, 151 
Vaginitis, acute. 110 
gonorrheal, 94. 9? 
Vaginofixation. 67. 89 
Varicocele parovarialis, 151 
Venereal diseases, 139 
Ventrofixation. 67. 89 
Vesical calculi, diagnosis, 181 
etiology, 181 
symptoms, 181 
treatment. 183 
irrigations. 147 
paralysis, 145 
diagnosis, 146 
symptoms, 146 
treatment, 148 
spasm. 143 
diagnosis, 144 
symptoms, 143 
treatment. 148 
tuberculosis, 137, 139 
Vesicofixation, 67 
Vulva, condylomata of, 186 
cysts of, 187 
duplex, 29 
elephantiasis of, 100 
epithelioma of. 234 
fibromata of, 186 
fibromyomata of, 186 
fissures of. 155 
folliculitis of, 149, 150 
furunculosis of, 149 
hematoma of, 175 
histology of, 98 



272 



INDEX. 



Vulva, incontinence, 155, 158 

injuries of, 155 

lipomata of, 187 

lupus of, 137 

myxofibromata of, 186 

papillomata of, 186 

sarcoma of, 235 

tuberculosis of, 137, 138 
Vulvitis diabetica, 149, 150 

gonorrheal, 98 



Vulvitis, papillary, 149 
pruriginosa, 149, 150 



Yeast cultures in endometritis, 
110 

Z. 

Zestocausis, 115 



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[For List of Volumes in this Series , see next two pages. ) 
3 



SAUNDERS' MEDICAL HAND-ATLASES. 



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Atlas and Epitome of Internal Medicine and Clinical Diagnosis. 

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Atlas and Epitome of Syphilis and the Venereal Diseases. By 

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4 



SAUNDERS' MEDICAL HAND-ATLASES- 



VOLUMES IN PRESS FOR EARLY PUBLICATION. 

Atlas and Epitome of Diseases Caused by Accidents. By Dr. Ed. 

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Atlas and Epitome of Special Pathological Histology. By Dr. H. 
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Atlas and Epitome of General Pathological Histology. With an 
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Atlas and Epitome of Gynecology. By Dr. O. Schaffer, of the 
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IN PREPARATION. 

Atlas and Epitome of Orthopedic Surgery. By Dr. Schultess and 

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Atlas and Epitome of Operative Gynecology. By Dr. O. Schaffer, 

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Atlas and Epitome of Diseases of the Ear. Edited by Prof. Dr. 

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Atlas and Epitome of General Surgery. Edited by Dr. Marwedel, 

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Atlas and Epitome of Normal Histology. By Dr. Johannes Sobotta, 

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Atlas and Epitome of Topographical Anatomy. By Prof. Dr. 

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copious text. 

5 



W. B. SAUNDERS' 



*THE INTERNATIONAL TEXT-BOOK OF SURGERY. In 
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De Forest Willard. 



CATALOGUE OF MEDICAL WORKS. 7 

♦AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. Edited by 
William H. Howell, Ph. D., M. D., Professor of Physiology in the 
Johns Hopkins University, Baltimore, Md. One handsome octavo volume 
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I This work is the most notable attempt yet made in America to combine in 
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HENRY P. BOWDITCH, M. D., 

Professor of Physiology, Harvard Medi- 
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JOHN G. CURTIS, M. D., 

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and Surgeons). 

HENRY H. DONALDSON, Ph.D., 

Head-Professor of Neurology, Univer- 
sity of Chicago. 

W. H. HOWELL, Ph. D., M. D., 

Professor of Physiology, Johns Hopkins 
University. 

FREDERIC S. LEE, Ph.D., 

Adjunct Professor of Physiology, Colum- 
bia University, N. Y. (College of 
Physicians and Surgeons). 



WARREN P. LOMBARD, M.D., 

Professor of Physiology, University of 
Michigan. 

GRAHAM LUSK, Ph.D., 

Professor of Physiology, Yale MedicaJ 
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W. T. PORTER, M.D., 

Assistant Professor of Physiology, Har- 
vard Medical School. 

EDWARD T. REICHERT, M.D., 

Professor of Physiology, University of 
Pennsylvania. 

HENRY SEWALL, Ph.D., M.D.. 

Professorof Physiology, Medical Depart- 
ment, University of Denver. 



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men who are of eminent authority in their own special subjects." — London Lancet. 

" To the practitioner of medicine and to the advanced student this volume constitutes, 
we believe, the best exposition of the present status of the science of physiology in the Eng- 
lish language."— American Journal of the Medical Sciences. 



8 



W. B. SAUNDERS' 



*AN AMERICAN TEXT-BOOK OF APPLIED THERAPEU- 
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James C. Wilson, M. D., Professor of the Practice of Medicine and of 
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The arrangement of this volume has been based, so far as possible, upon 
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The articles, with two exceptions, are the contributions of American writers. 
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The list of contributors comprises the names of many who have acquired dis- 
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CONTRIBUTORS : 



Dr. I. E. Atkinson, Baltimore, Md. 
Sanger Brown, Chicago, lil. 
John B. Chapin, Philadelphia, Pa. 
William C. Dabney, Charlottesville, Va. 
John Chalmers DaCosta, Philada., Pa. 
I. N. Danforth, Chicago, 111. 
John L. Dawson, Jr., Charleston, S. C. 
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George Dock, Ann Arbor, Mich. 
Robert T. Edes, Jamaica Plain, Mass. 
Augustus A. Eshner, Philadelphia, Pa. 
J. T. Eskridge, Denver, Col. 
F. Forchheimer, Cincinnati, O. 
Carl Frese, Philadelphia, Pa. 
Edwin E. Graham, Philadelphia, Pa. 
John Guiteras, Philadelphia, Pa. 
Frederick P. Henry, Philadelphia, Pa. 
Guy Hinsdale, Philadelphia, Pa. 
Orville Horwitz, Philadelphia, Pa. 
W. W. Johnston, Washington, D. C. 
Ernest Laplace, Philadelphia, Pa. 
A. Laveran, Paris, France. 

"As a work either for study or reference it will be of great value to the practitioner, as 
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the most value. Taking it all in all, no recent publication on therapeutics can be compared 
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" The whole field of medicine has been well covered. The work is thoroughly practical, 
and while it is intended for practitioners and students, it is abetter book for the general 
practitioner than for the student. The young practitioner especially will find it extremely 
suggestive and helpful." — The Indian Lancet. 



Dr. James Hendrie Lloyd, Philadelphia, Pa. 
John Noland Mackenzie, Baltimore, Md. 
J. W. McLaughlin, Austin, Texas. 
A. Lawrence Mason, Boston, Mass. 
Charles K. Mills, Philadelphia, Pa. 
John K. Mitchell, Philadelphia, Pa. 
W. P. Northrup, New York City. 
William Osier, Baltimore, Md. 
Frederick A. Packard, Philadelphia, Pa. 
Theophilus Parvin, Philadelphia, Pa. 
Beaven Rake, London, England. 
E. O. Shakespeare, Philadelphia, Pa. 
Wharton Sinkler, Philadelphia,. Pa. 
Louis Starr, Philadelphia, Pa. 
Henry W. Stelwagon, Philadelphia, Pa. 
James Stewart, Montreal, Canada. 
Charles G. Stockton, Buffalo, N. Y. 
James Tyson, Philadelphia, Pa. 
Victor C. Vaughan, Ann Arbor, Mich. 
James T. Whittaker, Cincinnati, O. 
J. C. Wilson, Philadelphia, Pa. 



CATALOGUE OF MEDICAL WORKS. 



*AN AMERICAN TEXT-BOOK OF OBSTETRICS. Edited by 
Richard C. Norris, M. D. ; Art Editor, Robert L. Dickinson, M. D. 
One handsome octavo volume of over iooo pages, with nearly 900 colored 
and half-tone illustrations. Prices : Cloth, $7.00 net ; Sheep or Half 
Morocco, $8.00 net. 

The advent of each successive volume of the series of the American Text- 
Books has been signalized by the most flattering comment from both the Press 
and the Profession. The high consideration received by these text-books, and 
their attainment to an authoritative position in current medical literature, have 
been matters of deep international interest, which finds its fullest expression in 
the demand for these publications from all parts of the civilized world. 

In the preparation of the "American Text-Book of Obstetrics" the 
editor has called to his aid proficient collaborators whose professional prominence 
entitles them to recognition, and whose disquisitions exemplify Practical 
Obstetrics. While these writers were each assigned special themes for dis- 
cussion, the correlation of the subject-matter is, nevertheless, such as ensures 
logical connection in treatment, the deductions of which thoroughly represent 
the latest advances in the science, and which elucidate the best ??wdem methods 
of procedure. 

The more conspicuous feature of the treatise is its wealth of illustrative 
matter. The production of the illustrations had been in progress for several 
years, under the personal supervision of Robert L. Dickinson, M. D., to whose 
artistic judgment and professional experience is due the most sumptuously 
illustrated work of the period. By means of the photographic art, combined 
with the skill of the artist and draughtsman, conventional illustration is super- 
seded by rational methods of delineation. 

Furthermore, the volume is a revelation as to the possibilities that may be 
reached in mechanical execution, through the unsparing hand of its publisher. 



CONTRIBUTORS : 



Dr. James C. Cameron. 
Edward P. Davis. 
Robert L. Dickinson. 
Charles Warrington Earle. 
James H. Etheridge. 
Henry J. Garngues. 
Barton Cooke Hirst. 
Charles Jewett. 



Dr. Howard A. Kelly. 
Richard C. Norris. 
Chauncey D. Palmer. 
Theophilus Parvin. 
George A. Piersol. 
Edward Reynolds. 
Henry Schwarz. 



" At first glance we are overwhelmed by the magnitude of this work in several respects, 
viz. : First, by the size of the volume, then by the array of eminent teachers in this depart- 
ment who have taken part in its production, then by the profuseness and character of the 
illustrations, and last, but not least, the conciseness and clearness with which the text is ren- 
dered. This is an entirely new composition, embodying the highest knowledge of the art as 
it stands to-day by authors who occupy the front rank in their specialty, and there are many 
of them. We cannot turn over these pages without being struck by the superb illustrations 
which adorn so many of them. We are confident that this most practical work will find 
instant appreciation by practitioners as well as students." — New York Medical Times. 

Permit me to say that your American Text-Book of Obstetrics is the most magnificent 
medical work that 1 have ever seen. I congratulate you and thank you for this superb work 
which alone is sufficient to place you first in the ranks of medical publishers. 

With profound respect I am sincerely yours, Alex. J. C. Skene. 



IO IV. B. SAUNDERS' 



*AN AMERICAN TEXT-BOOK OF THE THEORY AND 
PRACTICE OF MEDICINE. By American Teachers. Edited 
by William Pepper, M. D., LL.D., Provost and Professor of the Theory 
and Practice of Medicine and of Clinical Medicine in the University of 
Pennsylvania. Complete in two handsome royal- octavo volumes of about 
iooo pages each, with illustrations to elucidate the text wherever necessary. 
Price per Volume : Cloth, $5.00 net; Sheep or Half-Morocco, $6.00 net. 



VOLUME I. COXTAIXS: 



Hygiene. — Fevers (Ephemeral, Simple Con- 
tinued, Typhus, Typhoid, Epidemic Cerebro- 
spinal Meningitis, and Relapsing). — Scarla- 
tina, Measles, Rotheln, Variola, Varioloid, 
Vaccinia, Varicella, Mumps. Whooping-cough, 
Anthrax, Hydrophobia, Trichinosis, Actino- 



mycosis, Glanders, and Tetanus. — Tubercu- 
losis, Scrofula, Syphilis, Diphtheria, Erysipe- 
las, Malaria, Cholera, and Yellow Fever.— 
Nervous, Muscular, and Mental Diseases etc. 



VOLUME II. CONTAINS: 



Urine (Chemistry and Microscopy). — Kid- 
ney and Lungs. — Air-passages (Larynx and 
Bronchi) and Pleura. — Pharynx, (Esophagus, 
Stomach and Intestines (including Intestinal 
Parasites), Heart, Aorta, Arteries and Veins. 



— Peritoneum, Liver, and Pancreas. — Diathet- 
ic Diseases (Rheumatism, Rheumatoid Ar- 
thritis, Gout, Lithaemia, and Diabetes.) — 
Blood and Spleen. — Inflammation, Embolism, 
Thrombosis, Fever, and Bacteriology. 



The articles are not written as though addressed to students in lectures, but 
are exhaustive descriptions of diseases, with the newest facts as regards Causa- 
tion, Symptomatology, Diagnosis, Prognosis, and Treatment, including a large 
number of approved formulae. The recent advances made in the study 
of the bacterial origin of various diseases are fully described, as well as the 
bearing of the knowledge so gained upon prevention and cure. The subjects 
of Bacteriology as a whole and of Immunity are fully considered in a separate 
section. 

Methods of diagnosis are given the most minute and careful attention, thus 
enabling the reader to learn the very latest methods of investigation without 
consulting works specially devoted to the subject. 

CONTRIBUTORS : 



Dr. J. S. Billings, Philadelphia. 
Francis Delafield, New York. 
Reginald H. Fitz, Boston. 
James W. Holland, Philadelphia. 
Henry M. Lyman, Chicago. 
William Osier, Baltimore. 



Dr. William Pepper, Philadelphia. 
W. Gilman Thompson, New York. 
W. H. Welch, Baltimore. 
James T. Whittaker, Cincinnati. 
James C. Wilson, Philadelphia. 
Horatio C. Wood, Philadelphia. 



" We reviewed the first volume of this work, and said : •' It is undoubtedly one of the best 
text-books on the practice of medicine which we possess.' A consideration of the second 
and last volume leads us to modify that verdict and to say that the completed work i-s, in our 
opinion, the best of its kind it has ever been our fortune to see. It is complete, thorough, 
accurate, and clear. It is well written, well arranged, well printed, well illustrated, and well 
bound. It is a model of what the modern text-book should be." — New York Medical Journal. 

" A library upon modern medical art. The work must promote the wider diffusion of 
sound knowledge." — American Lancet. 

" A trusty counsellor for the practitioner or senior student, on which he may implicitly 
"ely." — Edinburgh Medical Journal. 



CATALOGUE OF MEDICAL WORKS. II 

*AN AMERICAN TEXT-BOOK OF SURGERY. Edited by Wil- 
liam W. Keen, M. D., LL.D., and J. William W t hite, M. D., Ph. D. 
Forming one handsome royal octavo volume of 1230 pages (10x7 inches), 
with 496 wood-cuts in text, and 37 colored and half-tone plates, many of 
them engraved from original photographs and drawings furnished by the 
authors. Price : Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. 

THIRD EDITION. THOROUGHLY REVISED. 

In the present edition, among the new topics introduced are a full considera- 
tion of serum-therapy ; leucocytosis ; post-operative insanity; the use of dry heat 
at high temperatures ; Kronlein's method of locating the cerebral fissures ; 
Hoffa's and Lorenz's operations of congenital dislocations of the hip; Allis's re- 
searches on dislocations of the hip-joint ; lumbar puncture ; the forcible reposi- 
tion of the spine in Pott's disease ; the treatment of exophthalmic goiter ; the 
surgery of typhoid fever ; gastrectomy and other operations on the stomach ; 
new methods of operating upon the intestines ; the use of Kelly's rectal specula ; 
the surgery of the ureter ; Schleich's infiliration-method and the use of eucain 
for local anesthesia ; Krause's method of skin-grafting ; the newer methods of 
disinfecting the hands; the use of gloves, etc. The sections on Appendicitis, 
on Fractures, and on Gynecological Operations have been revised and enlarged. 
A considerable number of new illustrations have been added, and enhance the 
value of the work. 

The text of the entire book has been submitted to all the authors for their 
mutual criticism and revision — an idea in book-making that is entirely new and 
original. The book as a whole, therefore, expresses on all the important sur- 
gical topics of the day the consensus of opinion of the eminent surgeons who 
have joined in its preparation. 

One of the most attractive features of the book is its illustrations. Very 
many of them are original and faithful reproductions of photographs taken 
directly from patients or from specimens* 

CONTRIBUTORS % 



Dr. Phineas S. Conner, Cincinnati. 
Frederic S. Dennis, New York. 
William W. Keen, Philadelphia. 
Charles B. Nancrede, Ann Arbor, Mich. 
Roswell Park, Buffalo, New York. 
Lewis S. Pileher. New York. 



Dr. Nicholas Senn, Chicago. 

Francis J. Shepherd, Montreal, Canada. 

Lewis A. Stimson, New York. 

J. Collins Warren, Boston. 

J. William White, Philadelphia. 



" If this text-book is a fair reflex of the present position of American surgery, we must 
admit it is of a very high order of merit, and that English surgeons will have to look very 
carefuilv to their laurels if they are to preserve a position in the van of surgical practice."— 
London Lancet. 

Personally, 1 should not mind it being called THE Text-Book (instead of A Text-Book), 
for I know ot no single volume which contains so readable and complete an account of the 
science and art of Surgery as this does." — Edmund Owen, F. R. C. S., Member of the Board 
of Examiners of the Royal College of Surgeons, England. 



12 W. B. SAUNDERS 1 



^AN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL 
AND SURGICAL, for the use of Students and Practitioners. 

Edited by J. M. Baldy, M. D. Forming a handsome royal-octavo volume 
of 718 pages, with 341 illustrations in the text and 38 colored and half- 
tone plates. Prices : Cloth, $6.00 net; Sheep or Half-Morocco, $7.00 net. 

SECOND EDITION, THOROUGHLY REVISED. 

In this volume all anatomical descriptions, excepting those essential to a clear 
understanding of the text, have been omitted, the illustrations being largely de- 
pended upon to elucidate the anatomy of the parts. This work, which is 
thoroughly practical in its teachings, is intended, as its title implies, to be a 
working text-book. for physicians and students. A clear line of treatment has 
been laid down in every case, and although no attempt has been made to dis- 
cuss mooted points, still the most important of these have been noted and ex- 
plained. The operations recommended are fully illustrated, so that the reader, 
having a picture of the procedure described in the text under his eye, cannot fail 
to grasp the idea. All extraneous matter and discussions have been carefully 
excluded, the attempt being made to allow no unnecessary details to cumber 
the text. The subject-matter is brought up to date at every point, and the 
work is as nearly as possible the combined opinions of the ten specialists who 
figure as the authors. 

In the revised edition much new material has been added, and some of the 
old eliminated or modified. More than forty of the old illustrations have been 
replaced by new ones, which add very materially to the elucidation of the 
text, as they picture methods, not specimens. The chapters on technique and 
after-treatment have been considerably enlarged, and the portions devoted to 
plastic work have been so greatly improved as to be practically new. Hyste- 
rectomy has been rewritten, and all the descriptions of operative procedures 
have been carefully revised and fully illustrated. 



CONTRIBUTORS : 



Dr. Henry T. Byford. 
John M. Baldy. 
Edwin Cragin. 
J. H. Etheridge. 
William Goodell. 



Dr. Howard A. Kelly. 

Florian Krug. 
E. E. Montgomery. 
William R. Pryor. 
George M. Tuttle. 



"The most notable contribution to gynecological literature since 1887, .... and the most 
complete exponent of gynecology which we have. No subject seems to have been neglected, 
.... and the gynecologist and surgeon, and the general practitioner who has any desire 
to practise diseases of women, will find it of practical value. In the matter of illustrations 
and plates the book surpasses anything we have seen." — Boston Medical and Surgical 
Journal. 

" A thoroughly modern text-book, and gives reliable and well-tempered advice and in- 
struction." — Edinburgh Medical Journal. 

" The harmony of its conclusions and the homogeneity of its style give it an individuality 
which suggests a single rather than a multiple authorship." — Annals 0/ Surgery. 

" It must command attention and respect as a worthy representation of our advanced 
clinical teaching." — American Journal of Medical Sciences. 



CATALOGUE OF MEDICAL WORKS. 



13 



*AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHIL- 
DREN. By American Teachers. Edited by Louis Starr, M. D., 
assisted by Thompson S. Westcott, M. D. In one handsome royal-8vo 
volume of 1244 pages, profusely illustrated with wood-cuts, half-tone and 
colored plates. Net Prices: Cloth, $7.00; Sheep or Half-Morocco, $8.00. 

SECOND EDITION, REVISED AND ENLARGED. 

The plan of this work embraces a series of original articles written by some 
sixty well-known podiatrists, representing collectively the teachings of the most 
prominent medical schools and colleges of America. The work is intended to 
be a practical book, suitable for constant and handy reference by the practi- 
tioner and the advanced student. 

Especial attention has been given to the latest accepted teachings upon the 
etiology, symptoms, pathology, diagnosis, and treatment of the disorders of chil- 
dren, with the introduction of many special formulae and therapeutic procedures. 

In this new edition the whole subject matter has been carefully revised, new 
articles added, some original papers emended, and a number entirely rewritten. 
The new articles include "Modified Milk and Percentage Milk-Mixtures," 
" Lithemia," and a section on " Orthopedics." Those rewritten are " Typhoid 
Fever," "Rubella," "Chicken-pox," "Tuberculous Meningitis," "Hydroceph- 
alus," and "Scurvy;" while extensive revision has been made in "Infant 
Feeding," " Measles," " Diphtheria," and " Cretinism." The volume has thus 
been much increased in size by the introduction of fresh material. 

CONTRIBUTORS 1 



Dr. S. S. Adams, Washington. 

John Ashhurst, Jr., Philadelphia. 
A. D. Blackader, Montreal, Canada. 
David Bovaird, New York. 
Dillon Brown, New York. 
Edward M. Buckingham, Boston. 
Charles W. Burr, Philadelphia. 
W. E. Casselberry, Chicago. 
Henry Dwight Chapin, New York. 
W. S. Christopher, Chicago. 
Archibald Church, Chicago. 
Floyd M. Crandall, New York. 
Andrew F. Currier, New York. 
Roland G. Curtin, Philadelphia 
J. M. DaCos'a, Philadelphia. 
I. N. Danforth, Chicago. 
Edward P. Davis, Philadelphia. 
John B. Deaver, Philadelphia. 
G. E. de Schweinitz, Philadelphia. 
John Doming, New York. 
Charles Warrington Earle, Chicago. 
Wm. A. Edwards, San Diego, Cal. 
F. Forchheimer, Cincinnati. 
J. Henry Fruitnight, New York. 
J. P. Crozer Griffith, Philadelphia. 
W. A. Hardaway. St. Louis. 
M. P Hatfield, Chicago. 
Barton Cooke Hirst, Philadelphia. 
H. Illoway, Cincinnati. 
Henry Jackson, Boston. 
Charles G. Jennings, Detroit. 
Henry Koplik, New York. 



Dr. Thomas S. Latimer, Baltimore. 
Albert R. Leeds, Hoboken, N. J. 
J. Hendrie Lloyd, Philadelphia. 
George Roe Lockwood, New York. 
Henry M. Lyman, Chicago. 
Francis T. Miles, Baltimore. 
Charles K Mills, Philadelphia. 
James E. Moore, Minneapolis. 
F. Gordon Morrill, Boston. 
John H. Musser, Philadelphia. 
Thomas R. Neilson, Philadelphia. 
W. P. Northrup, New York. 
William Osier, Baltimore. 
Frederick A. Packard, Philadelphia. 
William Pepper, Philadelphia. 
Frederick Peterson, New York. 
W. T. Plant, Syracuse, New York. 
William M. Powell, Atlantic City. 
B. K. Rachford, Cincinnati. 
B. Alexander Randall, Philadelphia. 
Edward O. Shakespeare, Philadelphia 
F. C. Shattuck, Boston. 
J. Lewis Smith, New York. 
Louis Starr, Philadelphia. 
M. Allen Starr, New York. 
Charles W. Townsend, Boston. 
James Tyson, Philadelphia. 
W. S. Thayer, Baltimore. 
Victor C. Vaughan, Ann Arbor, Mich 
Thompson S. Westcott, Philadelphia. 
Henry R. Wharton, Philadelphia. 
J. William White, Philadelphia. 
J. C. Wilson, Philadelphia. 



14 



W. B. SAUNDERS" 



*AN AMERICAN TEXT-BOOK OF GENITO-URINARY AND 
SKIN DISEASES. By 47 Eminent Specialists and Teachers. Edited 
by L. Bolton Bangs, M. D., Professor of Genito-Urinary Surgery, Uni- 
versity and Bellevue Hospital Medical College, New York; and W. A. 
Hardaway, M. D., Professor of Diseases of the Skin, Missouri Medical 
College. Imperial octavo volume of 1229 pages, with 300 engravings ana 
20 full-page colored plates. Cloth, $7.00 net; Sheep or Half Morocco, 
$8.00 net. 

This addition to the series of " American Text-Books," it is confidently be- 
lieved, will meet the requirements of both students and practitioners, giving, as 
it does, a comprehensive and detailed presentation of the Diseases of the | 
Genito-Urinary Organs, of the Venereal Diseases, and of the Affections of the 
Skin. 

Having secured the collaboration of well-known authorities in the branches 
represented in the undertaking, the editors have not restricted the contributors 
ii. regard to the particular views set forth, but have offered every facility for the 
free expression of their individual opinions. The work will therefore be found 
to be original, yet homogeneous and fully representative of the several depart- 
ments of medical science with which it is concerned. 



CONTRIBUTORS \ 



. Chas. W. Allen, New York. 
I. E. Atkinson, Baltimore. 
L Bolton Bangs, New York. 
P. R. Bolton, New York. 
Lewis C. Bosher, Richmond, Va. 
John T. Bowen, Boston. 
J. Abbott Cantrell. Philadelphia. 
William T. Corlett, Cleveland, Ohio. 
B. Farquhar Curtis, New York. 
Condict W. Cutler, New York. 
Isadore Dyer, New Orleans. 
Christian Fenger, Chicago. 
John A. Fordyce, New York. 
Eugene Fuller, New York. 
R. H. Greene, New York. 
Joseph Grindon, St. Louis. 
Graeme M. Hammond, New York. 
W. A. Hardaway, St. Louis. 
M. B. Hartzell, Philadelphia. 
Louis Heitzmann. New York. 
James S- Howe, Boston. 
George T. Jackson, New York. 
Abraham Jacobi, New York. 
James C. Johnston. Mew Yo.iv. 



Dr. Hermann G. Klotz, New YqrK. 
J. H. Linsley, Burlington, V't. 
G. F. Lydston, Chicago, 

Hartwell N. Lyon, St. Louis. 

Edward Martin, Philadelphia. 

D. G. Montgomery, San Franciscc. 

James Pedersen, New York. 

S. Pollitzer, New York. 

Thomas R. Pooley. New York. 

A. R. Robinson, New York. 

A. E. Regensburger, San Franciscc. 

Francis J. Shepherd, Montreal, Can. 

S. C. Stanton, Chicago, 111. 

Emmanuel J. Stout. Philadelphia. 

Alonzo E. Taylor Philadelphia. 

Robert W. Taylor, New York. 

Paul Thorndike, Boston. 

H. Tuholske, St. Louis. 

Arthur Van Harlingen, Philadelphia. 

Francis S. Watson. Boston. 

J. William White, Philadelphia. 

J. McF. Winfield. Brooklyn. 

Alfred C. Wood, Philadeipnia. 



"This voluminous work is thoroughly up to date, and the chapters on genito-urmary dis- 
eases are especially valuable. The illustrations are fine and are mostly original. _ The section 
on dermatology is concise and in every way admirable."— Journal of the American Medical 
Association. 

" This volume is one of the best yet issued of the publisher's series of ' American Text- 
Books.' The list of contributors represents an extraordinary array of talent and extended 
experience. The book will easily take the place in comprehensiveness and value of the 
half dozen or more costly works on these subjects which have hitherto been necessary to a 
well-equipped library."— New York Polyclinic. 



CATALOGUE OF MEDICAL WORKS. 



15 



* AN AMERICAN TEXT-BOOK OF DISEASES OF THE EYE, 
EAR, NOSE, AND THROAT. Edited by George E. de Schweinitz, 

A. M., M. D., Professor of Ophthalmology, Jefferson Medical College ; and 

B. Alexander Randall, A. M., M. D., Clinical Professor of Diseases of 
the Ear, University of Pennsylvania. One handsome imperial octavo 
volume of 1251 pages; 766 illustrations, 59 of them colored. Prices: 
Cloth, $7.00 net; Sheep or Half- Morocco, $8.00 net. 

Just Issued. 

The present work is the only book ever published embracing diseases of the 
intimately related organs of the eye, ear, nose, and throat. Its special claim 
to favor is based on encyclopedic, authoritative, and practical treatment of the 
subjects. 

Each section of the book has been entrusted to an author who is specially 
identified with the subject on which he writes, and who therefore presents his 
case in the manner of an expert. Uniformity is secured and overlapping pre- 
vented by careful editing and by a system of cross-references which forms a 
special feature of the volume, enabling the reader to come into touch with all 
that is said on any subject in different portions of the book. 

Particular emphasis is laid on the most approved methods of treatment, so 
that the book shall be one to which the student and practitioner can refer for 
information in practical work. Anatomical and physiological problems, also, 
are fully discussed for the benefit of those who desire to investigate the more 
abstruse problems of the subject. 



CONTRIBUTORS : 



. Henry A. Alderton, Brooklyn. 
Harrison Allen, Philadelphia. 
Frank Allport, Chicago. 
Morris J. Asch. New York. 
S. C. Ayres, Cincinnati. 
R. O. Beard, Minneapolis. 
Clarence J. Blake, Boston. 
Arthur A. Bliss, Philadelphia. 
Albert P. Brubaker, Philadelphia. 
J. H. Bryan, Washington, D. C. 
Albert H. Buck, New York. 
F. Buller, Montreal, Can. 
Swan M. Burnett, Washington, D. C. 
Flemming Carrow, Ann Arbor, Mich. 
W. E. Casselberry, Chicago. 
Colman W. Cutler, New York. 
Edward B. Dench, New York. 
William S. Dennett, New York. 
George E. de Schweinitz, Philadelphia. 
Alexander Duane, New York. 
John W. Farlow, Boston, Mass. 
Walter J. Freeman, Philadelphia. 
H. Giflford, Omaha, Neb. 
W. C. Glasgow, St. Louis. 
J Orne Green, Boston. 
Ward A. Holden, New York. 
Christian R. Holmes, Cincinnati. 
William E. Hopkins, San Francisco. 
F. C. Hotz, Chicago. 
Lucien Howe, Buffalo, N. Y. 



Dr. Alvin A. Hubbell, Buffalo, N. Y. 
Edward Jackson, Philadelphia. 
J. Ellis Jennings, St. Louis. 
Herman Knapp, New York. 
Chas. W. Kollock, Charleston, S. C. 
G. A. Leland, Boston. 
J. A. Lippincott, Pittsburg, Pa. 
G. Hudson Makuen, Philadelphia. 
John H. McCollom, Boston. 
H. G. Miller, Providence, R. I. 
B. L. Miliiken, Cleveland, Ohio. 
Robert C. Myles, New York. 
James E. Newcomb, New York. 
R. J. Phiilips, Philadelphia. 
George A. Piersol, Philadelphia. 
W. P. Porcher, Charleston, S. C. 
B. Alex. Randall, Philadelphia. 
Robert L. Randolph, Baltimore. 
John O. Roe, Rochester, N. Y. 
Charles E. de M. Sajous, Philadelphia. 
J. E. Sheppard, Brooklyn, N. Y. 
E. L. Shurly, Detroit, Mich. 
William M. Sweet, Philadelphia. 
Samuel Theobald. Baltimore, Md. 
A. G. Thomson, Philadelphia. 
Clarence A. Veasey, Philadelphia. 
John E. Weeks, New York. 
Casey A. Wood, Chicago, 111. 
Jonathan Wright, Brooklyn. 
H. V. Wiirdemann, Milwaukee, Wis. 



i6 



W. B. SAUNDERS' 



*AN AMERICAN YEAR-BOOK OF MEDICINE AND SUR- 
GERY. A Yearly Digest of Scientific Progress and Authoritative 
Opinion in all branches of Medicine and Surgery, drawn from journals* 
monographs, and text-books of the leading American and Foreign authors 
and investigators. Collected and arranged, with critical editorial com- 
ments, by eminent American specialists and teachers, under the general 
editorial charge of George M. Gould, M. D. Volumes for 1896, '97, 
'98, and '99 each a handsome imperial octavo volume of about 1200 pages. - 
Prices : Cloth, $6.50 net ; Half- Morocco, $7.50 net. Year-Book for 1900 in 
two octavo volumes of about 600 pages each. Prices per volume : Cloth, 
$3.00 net; Half-Morocco, $3.75 net. 

In Two Volumes. No Increase in Price* 

In response to a widespread demand from the medical profession, the pub- 
lisher of the "American Year-Book of Medicine and Surgery" has decided to 
issue that well-known work in two volumes, Vol. I. treating of General Medi- 
cine, Vol. II. of General Surgery. Each volume is complete in itself, and 
the work is sold either separately or in sets. 

This division is made in such a way as to appeal to physicians from a class 
standpoint, one volume being distinctly medical, and the other distinctly surgi- 
cal. This arrangement has a two-fold advantage. To the physician who uses 
the entire book, it offers an increased amount of matter in the most convenient 
form for easy consultation, and without any increase in price; while the man 
who wants either the medical or the surgical section alone secures the complete 
consideration of his branch without the necessity of purchasing matter for which 
he has no use. 

CONTRIBUTORS : 



Vol. I. 
Dr. Samuel W. Abbott, Boston. 
Archibald Church, Chicago. 
Louis A. Duhring, Philadelphia. 
D. L. Edsall, Philadelphia. 
Alfred Hand, Jr., Philadelphia. 
M. B. Hartzell, Philadelphia. 
Reid Hunt, Baltimore. 
Wyatt Johnston, Montreal. 
Walter Jones, Baltimore. 
David Riesman, Philadelphia. 
Louis Starr, Philadelphia. ^ 
Alfred Stengel, Philadelphia. 
A. A. Stevens, Philadelphia. 
G. N. Stewart. Cleveland. 
Reynold W. Wilcox, New York City. 



Vol. II. 
Dr. J. Montgomery Baldy, Philadelphia. 
Charles H. Burnett, Philadelphia. 
J. Chalmers DaCosta, Philadelphia. 
W. A. N. Dorland, Philadelphia. 
Virgil P. Gibney, New York City. 
C. H. Hamann, Cleveland. 
Howard F. Hansell, Philadelphia. 
Barton Cooke Hirst, Philadelphia. 
E. Fletcher lngals, Chicago. 
W. W. Keen, Philadelphia. 
Henry G. Ohls, Chicago. 
Wendell Reber, Philadelphia. 
J. Hilton Waterman, New York City. 



" It is difficult to know which to admire most — the research and industry of the distin- 
guished band of experts whom Dr. Gould has enlisted in the service of the Year-Book, or fche 
wealth and abundance of the contributions to every department of science that have been 
deemed worthy of analysis. ... It is much more than a mere compilation of abstracts, for, 
as each section is entrusted to experienced and able contributors, the reader has the advan- 
tage of certain critical commentaries and expositions . . . proceeding from writers fully 
qualified to perform these tasks. ... It is emphatically a book which should find a place in 
every medical library, and is in several respects more useful than the famous ' Jahrbucher' 
of Germany." — London Lancet. 






CATALOGUE OF MEDICAL WORKS. \J 

* ANOMALIES AND CURIOSITIES OF MEDICINE. By George 
M. Gould, M.D., and Walter L. Pyle, M.D. An encyclopedic collec- 
tion of are and extraordinary cases and of the most striking instances of 
abnormality in all branches of Medicine and Surgery, derived from an ex- 
haustive research of medical literature from its origin to the present day, 
abstracted, classified, annotated, and indexed. Handsome imperial octavo 
volume of 968 pages, with 295 engravings in the text, and 12 full-page 
plates. Cloth, $3.00 net ; Half-Morocco, $4.00 net. 

POPULAR EDITION REDUCED FROM $6*00 to $3.00. 

In view of the greatsuccess of this magnificent work, the publisher has decided 
to issue a " Popular Edition " at a price so low that it may be procured by every 
student and practitioner of medicine. Notwithstanding the great reduction in 
price, there will be no depreciation in the excellence of typography, paper, and 
binding that characterized the earlier editions. 

Several years of exhaustive research have been spent by the authors in the 
great medical libraries of the United States and Europe in collecting the mate- 
rial for this work. Medical literature of all ages and all languages has 
been carefully searched, as a glance at the Bibliographic Index will show. The 
facts, which will be of extreme value to the author and lecturer, have been 
arranged and annotated, and full reference footnotes given. 

" One of the most valuable contributions ever made to medical literature. It is, so far as 
we know, absolutely unique, and every page is as fascinating as a novel. Not alone for the 
medical profession has this volume value : it will serve as a book of reference for all who are 
interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical Jour- 
nal. 

NERVOUS AND MENTAL DISEASES. By Archibald Church, 
M. D., Professor of Clinical Neurology, Mental Diseases, and Medical 
Jurisprudence, Northwestern University Medical School; and Frederick 
Peterson, M. D., Clinical Professor of Mental Diseases, Woman's Medi- 
cal College, New York. Handsome octavo volume of 843 pages, with 
over 300 illustrations. Prices: Cloth, $5.00 net; Half-Morocco, $6.00 
net. 

Second Edition. 

This book is intended to furnish students and practitioners with a practical, 
working knowledge of nervous and mental diseases. Written by men of wide 
experience and authority, it presents the many recent additions to the subject. 
The book is not filled with an extended dissertation on anatomy and pathology, 
but, treating these points in connection with special conditions, it lays particular 
stress on methods of examination, diagnosis, and treatment. In this respect the 
work is unusually complete and valuable, laying down the definite courses of 
procedure which the authors have found to be most generally satisfactory. 

"The work is an epitome of what is to-day known of nervous diseases prepared for the 
student and practitioner in the light of the author's experience . . . We believe that no work 
presents the difficult subject of insanity in such a reasonable and readable way." — Chicago 
Medical Recorder. 



1 8 W. B. SAUNDERS' 



DISEASES OF THE NOSE AND THROAT. By D. Braden Kyle, 

M. D., Clinical Professor of Laryngology and Rhinology, Jefferson Medi- 
cal College, Philadelphia; Consulting Laryngologist, Rhinologist, and 
Otologist, St. Agnes' Hospital. Octavo volume of 646 pages, with over 
150 illustrations and 6 lithographic plates. Cloth, $4.00 net; Half-Mo- 
rocco, $5.00 net. 

Just Issued. 

This book presents the subject of Diseases of the Nose and Throat in as con- 
cise a manner as is consistent with clearness, keeping in mind the needs of the 
student and general practitioner as well as those of the specialist. The arrange- 
ment and classification are based on modern pathology, and the pathological 
views advanced are supported by drawings of microscopical sections made in the 
author's own laboratory. These and the other illustrations are particularly fine, 
being chiefly original. With the practical purpose of the book in mind, ex- 
tended consideration has been given to details of treatment, each disease being 
considered in full, and definite courses being laid down to meet special condi- 
tions and symptoms. 

" It is a thorough, full, and systematic treatise, so classified and arranged as greatly to facili- 
tate the teaching of laryngology and rhinology to classes, and must prove most convenient 
and satisfactory as a reference book, both for students and practitioners." — International 
Medical Magazine. 

THE HYGIENE OF TRANSMISSIBLE DISEASES ; theirCausa- 
tion, Modes of Dissemination, and Methods of Prevention. By 
A. C. Abbott, M. D., Professor of Hygiene in the University of Pennsyl- 
vania ; Director of the Laboratory of Hygiene. Octavo volume of 311 
pages, with charts and maps, and numerous illustrations. Cloth, $2.00 net. 



Just Issued. 

It is not the purpose of this work to present the subject of Hygiene in the 
comprehensive sense ordinarily implied by the word, but rather to deal directly 
with but a section, certainly not the least important, of the subject — viz., that 
embracing a knowledge of the preventable specific diseases. The book aims to 
furnish information concerning the detailed management of transmissible dis- 
eases. Incidentally there are discussed those numerous and varied factors that 
have not only a direct bearing upon the* incidence and suppression of such dis- 
eases, but are of general sanitary importance as well. 

" The work is admirable in conception and no less so in execution. It is a practical work, 
simply and lucidly written, and it should prove a most helpful aid in that department of 
medicine which is becoming daily of increasing importance and application — namely, prophy- 
laxis." — Philadelphia Medical Journal. 

" It is scientific, but not too technical ; it is as complete as our present-day knowledge of 
hygiene and sanitation allows, and it is in harmony with the efforts of the profession, which 
are tending more and more to methods of prophylaxis. For the student and for the practi- 
tioner it is well nigh indispensable." — Medical News, New York. 



CATALOGUE OF MEDICAL WORKS. 1 9 

A TEXT-BOOK OF EMBRYOLOGY. By John C. Heisler, M. D.. 

Professor of Anatomy in the Medico- Chirurgical College, Philadelphia. 
Octavo volume of 405 pages, with 190 illustrations, 26 in colors. Cloth 
$2.50 net. 

Just Issued. 

The facts of embryology having acquired in recent years such great interesl 
in connection with the teaching and with the proper comprehension of human 
anatomy, it is of first importance to the student of medicine that a concise and 
yet sufficiently full text-book upon the subject be available. It was with the 
aim of presenting such a book that this volume was written, the author, in his 
experience as a teacher of anatomy, having been impressed with the fact that 
students were seriously handicapped in their study of the subject of embryology 
by the lack of a text-book full enough to be intelligible, and yet without that 
minuteness of detail which characterizes the larger treatises, and which so often 
serves only to confuse and discourage the beginner. 

" In short, the book is written to fill a want which has distinctly existed and which it 
definitely meets ; commendation greater than this it is not possible to give to anything." — 
Medical News, New York. 

A MANUAL OF DISEASES OF THE EYE. By Edward Jack- 
son, A. M., M. D., sometime Professor of Diseases of the Eye in the Phila- 
delphia Polyclinic and College for Graduates in Medicine. I2mo, 604 
pages, with 178 illustrations from drawings by the author. Cloth, $2.50 net. 

Just Issued. 

This book is intended to meet the needs of the general practitioner of medi- 
cine and the beginner in ophthalmology. More attention is given to the condi- 
tions that must be met and dealt with early in ophthalmic practice than to the 
rarer diseases and more difficult operations that may come later. 

It is designed to furnish efficient aid in the actual work of dealing with dis- 
ease, and therefore gives the place of first importance to the recognition and 
management of the conditions that present themselves in actual clinical work. 

LECTURES ON THE PRINCIPLES OF SURGERY. By Charles 
B. Nancrede, M. D., LL.D., Professor of Surgery and of Clinical Surgery, 
University of Michigan, Ann Arbor. Handsome octavo, 398 pages, illus- 
trated. Cloth, $2.50 net. 

Just Issued. 

The present book is based on the lectures delivered by Dr. Nancrede to his 
undergraduate classes, and is intended as a text-book for students and a practi- 
cal help for teachers. By the careful elimination of unnecessary details of 
pathology, bacteriology, etc., which are amply provided for in other courses of 
study, space is gained for a more extended consideration of the Principles of 
Surgery in themselves, and of the application of these principles to methods 
of practice. 



20 W. B. SAUNDERS' 



A TEXT-BOOK OF PATHOLOGY. By Alfred Stengel, M. D., 

Professor of Clinical Medicine in the University of Pennsylvania ; Physi- 
cian to the Philadelphia Hospital ; Physician to the Children's Hospital, 
Philadelphia. Handsome octavo volume of 848 pages, with 362 illustra- 
tions, many of which are in colors. Prices: Cloth, $4.00 net; Half- 
Morocco, $5.00 net. 



Second Edition. 

In this work the practical application of pathological facts to clinical medicine 
is considered more fully than is customary in works on pathology. While the 
subject of pathology is treated in the broadest way consistent with the size of 
the book, an effort has been made to present the subject from the point of view ' 
of the clinician. The general relations of bacteriology to pathology are dis- 
cussed at considerable length, as the importance of these branches deserves. It 
will be found that the recent knowledge is fully considered, as well as older and 
more widely-known facts. 

" I consider the work abreast of modern pathology, and useful to both students and prac- 
titioners. It presents in a concise and well-considered form the essential facts of general and 
special pathological anatomy, with more than usual emphasis upon pathological physiology." 
— Willi aim H. Welch, Professor of Pathology , Johns Hopkins University, Baltimore, Md. 

"I regard it as the most serviceable text-book for students on this subject yet written by 
an American author." — L. Hektoen, Professor of Pathology, Rush Medical College, 
Chicago, III. 

A TEXT-BOOK OF OBSTETRICS. By Barton Cooke Hirst, M.D., 
Professor of Obstetrics in the University of Pennsylvania. Handsome oc- 
tavo volume of 846 pages, with 618 illustrations and seven colored plates. 
Prices: Cloth, $5.00 net; Half-Morocco, $6.00 net. 

Second Edition. 

This work, which has been in course of preparation for several years, is in- 
tended as an ideal text-book for the student no less than an advanced treatise 
for the obstetrician and for general practitioners. It represents the very latest 
teaching in the practice of obstetrics by a man of extended experience and 
recognized authority. The book emphasizes especially, as a work on obstetrics 
should, the practical side of the subject, and to this end presents an unusually 
large collection of illustrations. A great number of these are new and original, 
and the whole collection will form a complete atlas of obstetrical practice. 
An extremely valuable feature of the book is the large number of refer- 
ences to cases, authorities, sources, etc., forming, as it does, a valuable bib- 
liography of the most recent and authoritative literature on the subject 
of obstetrics. As already stated, this work records the wide practical ex- 
perience of the author, which fact, combined with the brilliant presentation 
of the subject, will doubtless render this one of the most notable books on 
obstetrics that has yet appeared. 

" The illustrations are numerous and are works of art, many of them appearing for the 
first time. The arrangement of the subject-matter, the foot-notes, and index are beyond 
criticism. The author's style, though condensed, is singularly clear, so that it is never 
necessary to re-read a sentence in order to grasp its meaning. As a true model of what a 
modern text-book in obstetrics should be, we feel justified in affirming that Dr. Hirst's 
book is without a rival." — New York Medical Record. 



CATALOGUE OF MEDICAL WORKS. 21 

A TEXT-BOOK OF THE PRACTICE OF MEDICINE. By 

James M. Anders, M.D., Ph.D., LL.D., Professor of the Practice of 
Medicine and of Clinical Medicine, Medico-Chirurgical College, Philadel- 
phia. In one handsome octavo volume of 1292 pages, fully illustrated. 
Cloth, $5.50 net ; Sheep or Half-Morocco, $6.50 net. 

THIRD EDITION, THOROUGHLY REVISED. 

The present edition is the result of a careful and thorough revision. A few 
new subjects have been introduced : Glandular Fever, Ether-pneumonia, Splenic 
Anemia, Meralgia Paresthetica, and Periodic Paralysis. The affections that 
have been substantially rewritten are: Plague, Malta Fever, Diseases of the 
Thymus Gland, Liver Cirrhoses, and Progressive Spinal Muscular Atrophy. 
The following articles have been extensively revised : Typhoid Fever, Yellow 
Fever, Lobar Pneumonia, Dengue, Tuberculosis, Diabetes Mellitus, Gout, Ar- 
thritis Deformans, Autumnal Catarrh, Diseases of the Circulatory System, more 
particularly Hypertrophy and Dilatation of the Heart, Arteriosclerosis and 
Thoracic Aneurysm, Pancreatic Hemorrhage, Jaundice, Acute Peritonitis, Acute 
Yellow Atrophy, Hematoma of Dura Mater, and Scleroses of the Brain. The 
preliminary chapter on Nervous Diseases is new, and deals with the subject of 
localization and the various methods of investigating nervous .affections. 

" It is an excellent book — concise, comprehensive, thorough, and up to date. It is a 
credit to you ; but, more than that, it is a credit to the profession of Philadelphia — to us." 
— James C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jeffer- 
son Medical College, Philadelphia. 

" The book can be unreservedly recommended to students and practitioners as a safe, full 
compendium of the knowledge of internal medicine of the present day ... It is a work 
thoroughly modern in every sense." — Medical News, New York. 

DISEASES OF THE STOMACH. By William W. Van Valzah, 

M. D., Professor of General Medicine and Diseases of the Digestive System 
and the Blood, New York Polyclinic ; and J. Douglas Nisbet, M. D., 
Adjunct Professor cf General Medicine and Diseases of the Digestive Sys- 
tem and the Blood, New York Polyclinic. Octavo volume of 674 pages, 
illustrated. Cloth, $3.50 net. 

An eminently practical book, intended as a guide to the student, an aid to the 
physician, and a contribution to scientific medicine. It aims to give a complete 
description of the modern methods of diagnosis and treatment of diseases of the 
stomach, and to reconstruct the pathology of the stomach in keeping with the 
revelations of scientific research. The book is clear, practical, and complete, 
and contains the results of the authors' investigations and of their extensive ex- 
perience as specialists. Particular attention is given to the important subject of 
dietetic treatment. The diet-lists are very complete, and are so arranged that 
selections can readily be made to suit individual cases. 

" This is the most satisfactory work on the subject in the English language." — Chicago 
Medical Recorder. 

" The article on diet and general medication is one of the most valuable in the book, and 
should be read by every practising physician." — New York Medical Journal. 



22 m B. SAUNDERS' 



SURGICAL DIAGNOSIS AND TREATMENT. By J. W. Mao 

donald, M. D., Edin., F. R. C. S., Edin., Professor of the Practice of Sur- 
gery and of Clinical Surgery in Hamline University ; Visiting Surgeon to St. 
Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of 800 
pages, profusely illustrated. Cloth, $5.00 net; Half-Morocco, $6.00 net. 
This work aims in a comprehensive manner to furnish a guide in matters of 
surgical diagnosis. It sets forth in a systematic way the necessities of examina- 
tions and the proper methods of making them. The various portions of the 
body are then taken up in order and the diseases and injuries thereof succinctly 
considered and the treatment briefly indicated. Practically all the modern and 
approved operations are described with thoroughness and clearness. The work 
concludes with a chapter on the use of the Rontgen rays in surgery. 

" The work is brimful of just the kind of practical information that is useful alike to 
students and practitioners. It is a pleasure to commend the book because of its intrinsic 
value to the medical practitioner." — Cincinnati Lancet-Clinic. 

PATHOLOGICAL TECHNIQUE. A Practical Manual for Laboratory 
Work in Pathology, Bacteriology, and Morbid Anatomy, with chapters on 
Post-Mortem Technique and the Performance of Autopsies. By Frank 
B. Mallory, A. M., M. D., Assistant Professor of Pathology, Harvard 
University Medical School, Boston ; and James H. Wright, A. M., M. D., 
Instructor in Pathology, Harvard University Medical School, Boston. Oc- 
tavo volume of 396 pages, handsomely illustrated. Cloth, $2.50 net. 
This book is designed especially for practical use in pathological laboratories, 
both as a guide to beginners and as a source of reference for the advanced. The 
book will also meet the wants of practitioners who have opportunity to do general 
pathological work. Besides the methods of post-mortem examinations and of 
bacteriological and histological investigations connected with autopsies, the 
special methods employed in clinical bacteriology and pathology have been 
fully discussed. 

" One of the most complete works on the subject, and one which should be in the library 
of every physician who hopes to keep pace with the great advances made in pathology." — 
yournal of American Medical Association. 

THE SURGICAL COMPLICATIONS AND SEQUELS OF TY- 
PHOID FEVER. By Wm. W. Keen, M. D., LL.D., Professor of the 
Principles of Surgery and of Clinical Surgery, Jefferson Medical College, 
Philadelphia. Octavo volume of 386 pages, illustrated. Cloth, $3.00 net. 
This monograph is the only one in any language covering the entire subject 
of the Surgical Complications and Sequels of Typhoid Fever. The work will 
prove to be of importance and interest not only to the general surgeon and phy- 
sician, but also to many specialists — laryngologists, ophthalmologists, gynecolo- 
gists, pathologists, and bacteriologists — as the subject has an important bearing 
upon each one of their spheres. The author's conclusions are based on reports 
of over 1700 cases, including practically all those recorded in the last fifty years. 
Reports of cases have been brought down to date, many having been added 
while the work was in press. 

" This is. probably the first and only work in the English language that gives the reader a 
clear view of what typhoid fever really is, and what it does and can do to the human organ- 
ism. This book should be in the possession of every medical man in America." — American 
Medico-Surgical Bulletin. 



CATALOGUE OF MEDICAL WORKS. 2$ 



MODERN SURGERY, GENERAL AND OPERATIVE. By John 
Chalmers DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medi- 
cal College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. 
Handsome octavo volume of 911 pages, profusely illustrated. Cloth, $4.00 
net ; Half- Morocco, $5.00 net. 

Second Edition, Rewritten and Greatly Enlarged. 

The remarkable success attending DaCosta's Manual of Surgery, and the 
general favor with which it has been received, have led the author in this 
revision to produce a complete treatise on modern surgery along the same lines 
that made the former edition so successful. The book has been entirely re- 
written and very much enlarged. The old edition has long been a favorite not 
only with students and teachers, but also with practising physicians and sur- 
geons, and it is believed that the present work will find an even wider field of 
usefulness. 

"We know of no small work on surgery in the English language which so well fulfils the 
requirements of the modern student." — Medico-Chirurgical Journal, Bristol, England. 

" The author has presented concisely and accurately the principles of modern surgery. 
The book is a valuable one which can be recommended to students and is of great value to 
the general practitioner." — American Journal of the Medical Sciences. 

A MANUAL OF ORTHOPEDIC SURGERY. By James E. Moore, 
M.D., Professor of Orthopedics and Adjunct Professor of Clinical Surgery, 
University of Minnesota, College of Medicine and Surgery. Octavo volume 
of 356 pages, with 177 beautiful illustrations from photographs made spec- 
ially for this work. Cloth, $2.50 net. 

A practical book based upon the author's experience, in which special stress 
is laid upon early diagnosis and treatment such as can be carried out by the 
general practitioner. The teachings of the author are in accordance with his 
belief that true conservatism is to be found in the middle course between the 
surgeon who operates too frequently and the orthopedist who seldom operates. 

" A very demonstrative work, every illustration of which conveys a lesson. The work is 
a most excellent and commendable one, which we can certainly endorse with pleasure." — 
St. Louis Medical and Surgical Journal. 

ELEMENTARY BANDAGING AND SURGICAL DRESSING. 

With Directions concerning the Immediate Treatment of Cases of Emer- 
gency. For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., 
late Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80 
illustrations. Cloth, flexible covers, 75 cents net. 

This little book is chiefly a condensation of those portions of Pye's " Surgical 
Handicraft" which deal with bandaging, splinting, etc., and of those which 
treat of the management in the first instance of cases of emergency. The 
directions given are thoroughly practical, and the book will prove extremely use- 
ful to students, surgical nurses, and dressers. 

"The author writes well, the diagrams are clear, and the book itself is small and portable, 
although the paper and type are good." — British Medical Journal. 



24 W. B. SAUNDERS' 



A TEXT-BOOK OF MATERIA MEDICA, THERAPEUTICS 
AND PHARMACOLOGY. By George F. Butler, Ph.G., M.D., 

Professor of Materia Medica and of Clinical Medicine in the College of 
Physicians and Surgeons, Chicago; Professor of Materia Medica and 
Therapeutics, Northwestern University, Woman's Medical School, etc. 
Octavo, 874 pages, illustrated. Cloth, $4.00 net; Sheep, $5.00 net. 
Third Edition, Thoroughly Revised, 
A clear, concise, and practical text-book, adapted for permanent reference no 
less than for the requirements of the class-room. 

The recent important additions made to our knowledge of the physiological 
action of drugs are fully discussed in the present edition. The book has been 
thoroughly revised and many additions have been made.- 

" Taken as a whole, the book may fairly be considered as one of the most satisfactory of any 
single-volume works on materia medica in the market/'— Journal of the American Medical 
Association. 

TUBERCULOSIS OF THE GENITO-URINARY ORGANS, 
MALE AND FEMALE. By Nicholas Senn, M.D., Ph.D., LL.D., 
Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical 
College, Chicago. Handsome octavo volume of 320 pages, illustrated^ 
Cloth, $3.00 net. 

Tuberculosis of the male and female genito-urinary organs is such a frequent, 
distressing, and fatal affection that a special treatise on the subject appears to 
fill a gap in medical literature. In the present work the bacteriology of the sub- 
ject has received due attention, the modern resources employed in the differen- 
tial diagnosis between tubercular and other inflammatory affections are fully 
described, and the medical and surgical therapeutics are discussed in detail. 

"An important book upon an important subject, and written by a man of mature judg- 
ment and wide experience. • The author has given us an instructive book upon one of the 
most importanr subjects of the day." — Clinical Reporter. 

"A work which adds another to the many obligations the profession owes the talented 
author." — Chicago Medical Recorder. 

A TEXT-BOOK OF DISEASES OF WOMEN. By Charles B. 
Penrose, M.D., Ph.D., Professor of Gynecology in the University of 
Pennsylvania; Surgeon to the Gynecean Hospital, Philadelphia. Octavo 
volume of 531 pages, with 217 illustrations, nearly all from drawings made 
for this work. Cloth, $3.75 net. 

Third Edition, Revised. 
In this work, which has been written for both the student of gynecology and 
the general practitioner, the author presents the best teaching of modern gyne- 
cology untrammelled by antiquated theories or methods of treatment. In most 
instances but one plan of treatment is recommended, to avoid confusing the 
student or the physician who consults the book for practical guidance. 

" I shall value very highly the copy of Penrose's ' Diseases of Women' received. I have 
already recommended it to my class as THE BEST book." — Howard A. Kelly, Professor 
of Gynecology and Obstetrics , Johns Hopkins University, Baltimore, Md. 

" The book is to be commended without reserve, not only to the student but to the general 
practitioner who wishes to have the latest and best modes of treatment explained with absolute 
clearness." — Therapeutic Gazette. 



CATALOGUE OF MEDICAL WORKS. 2$ 

SURGICAL PATHOLOGY AND THERAPEUTICS. By John 
Collins Warren, M. D., LL.D., Professor of Surgery, Medical Depart- 
ment Harvard University. Handsome octavo, 832 pages, with 136 relief 
and lithographic illustrations, 33 of which are printed in colors. 

Second Edition, 

with an Appendix devoted to the Scientific Aids to Surgical Diagnosis, and 
a series of articles on Regional Bacteriology. Cloth, $5.00 net; Half- 
Morocco, $6.00 net. 

Without Exception, the Illustrations are the Best ever Seen in a 
Work of this Kind. 

"A most striking and very excellent feature of this book is its illustrations. Without ex- 
ception, from the point of accuracy and artistic merit, they are the best ever seen in a work 
of this kind. * * * Many of those representing microscopic pictures are so perfect in their 
coloring and detail as almost to give the beholder the impression that he is looking down the 
barrel of a microscope at a well-mounted section." — Annals of Surgery, Philadelphia. 

" It is the handsomest specimen of book-making * * * that has ever been issued from the 
American medical press." — American Journal of the Medical Sciences, Philadelphia. 

PATHOLOGY AND SURGICAL TREATMENT OF TUMORS. 

By N. Senn, M. D., Ph. D., LL. D., Professor of Practice of Surgery and 
of Clinical Surgery, Rush Medical College; Professor of Surgery, Chicago 
Polyclinic ; Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, 
St. Joseph's Hospital, Chicago. One volume of 710 pages, with 515 
engravings, including full-page colored plates. New and enlarged Edition 
in Preparation. 

Books specially devoted to this subject are few, and # in our text-books and 
.systems of surgery this part of surgical pathology is usually condensed to a de- 
gree incompatible with its scientific and clinical importance. The author spent 
many years in collecting the material for this work, and has taken great pains 
to present it in a manner that should prove useful as a text-book for the student, 
a work of reference for the practitioner, and a reliable guide for the surgeon. 

" The most exhaustive of any recent book in English on this subject. It is well illus- 
trated, and will doubtless remain as the principal monograph on the subject in our language 
for some years. The book is handsomely illustrated and printed, .... and the author has 
given a notable and lasting contribution to surgery." — Journal of the American Medical 
Association, Chicago. 

LECTURES ON RENAL AND URINARY DISEASES. By 

Robert Saundby, M. D., Edin., Fellow of the Royal College of Physicians, 
London, and of the Royal Medico-Chirurgical Society; Physician to the 
General Hospital. Octavo volume of 434 pages, with numerous illustra- 
tions and 4 colored plates. Cloth, $2.50 net. 

"The volume makes a favorable impression at once. The style is clear and succinct. 
We cannot find any part of the subject in which the views expressed are not carefully thought 
out and fortified by evidence drawn from the most recent sources. The book may be cordially 
recommended." — British Medical Journal. 



26 W. B. SAUNDERS' 



A HANDBOOK FOR NURSES. By J. K. Watson, M.D., Edin., 
Assistant House-Surgeon, Sheffield Royal Hospital. American Edition, 
under the supervision of A. A. Stevens, A. M., M. D., Professor of 
Pathology, Woman's Medical College, Philadelphia. i2mo, 413 pages, 
73 illustrations. Cloth, $1.50 net. 

This work aims to supply in one volume that information which so many 
nurses at the present time are trying to extract from various medical works, and 
to present that information in a suitable form. Nurses must necessarily acquire 
a certain amount of medical knowledge, and the author of this book has aimed 
judiciously to cater to this need with the object of directing the nurses' pursuit 
of medical information in proper and legitimate channels. The book represents 
an entirely new departure in nursing literature, insomuch as it contains useful 
information on medical and surgical matters hitherto only to be obtained from 
expensive works written expressly for medical men. 

A NEW PRONOUNCING DICTIONARY OF MEDICINE, with 
Phonetic Pronunciation, Accentuation, Etymology, etc. By John 
M. Keating, M. D., LL.D., Fellow of the College of Physicians of Phila- 
delphia; Editor " Cyclopaedia of the Diseases of Children," etc.; and 
Henry Hamilton, with the Collaboration of J. Chalmers DaCosta, 
M. D., and Frederick A. Packard, M. D. One very attractive volume 
of over 800 pages. Second Revised Edition. Prices: Cloth, $5.00 net; 
Sheep or Half-Morocco, $6.00 net; with Denison's Patent Ready- Refer- 
ence Index ; without patent index, Cloth, $4.00 net ; Sheep or Half- 
Morocco, $5.00 net. 

PROFESSIONAL OPINIONS. 

" I am much pleased with Keating's Dictionary, and shall take pleasure in recommending 
it to my classes." 

Henry M. Lyman, M. D., 
Professor of Principles and Practice of Medicine, Rtish Medical College, Chicago, III. 

" I am convinced that it will be a very valuable adjunct to my study-table, convenient in 
size and sufficiently full for ordinary use." 

C. A. LlNDSLEY, M. D., 

Professor of Theory and Practice of Medicine, Medical Dept. Yale University; 

Secretary Connecticut State Board of Health, New Haven, Co?m x 

AUTOBIOGRAPHY OF SAMUEL D. GROSS, M. D., Emeritus Pro- 
fessor of Surgery in the Jefferson Medical College of Philadelphia, with 
Reminiscences of His Times and Contemporaries. Edited by his sons, 
Samuel W. Gross, M. D., LL.D., and A. Haller Gross, A.M., of the 
Philadelphia Bar. Preceded by a Memoir of Dr. Gross, by the late 
Austin Flint, M. D., LL.D. In two handsome volumes, each containing 
over 400 pages, demy 8vo, extra cloth, gilt tops, with fine Frontispiece 
engraved on steel. Price per Volume, $2.50 net. 



CATALOGUE OF MEDICAL WORKS. 2/ 

PRACTICAL POINTS IN NURSING. For Nurses in Private 
Practice. By Emily A. M. Stoney, Graduate of the Training-School 
for Nurses, Lawrence, Mass. ; Superintendent of the Training-School for 
Nurses, Carney Hospital, South Boston, Mass. 456 pages, handsomely 
illustrated with 73 engravings in the text, ana 9 colored and half-tone 
Diates. Cloth. Price, $1.75 neK e 

SECOND EDITION, THOROUGHLY REVISED. 

In this volume the author explains, in popular language and in the shortest 
possible form, the entire range of private nursing as distinguished from hospital 
nursing, and the nurse is instructed how best to meet the various emergencies of 
medical and surgical cases when distant from medical or surgical aid or when 
thrown on her own resources. 

An especially valuable' feature of the work will be found in the directions to 
the nurse how to improvise everything ordinarily needed in the sick-room, where 
the embarrassment of the nurse, owing to' the want of proper appliances, is fre- 
quently extreme. 

The work has been logically divided into the following sections : 

I. The Nurse : her responsibilities, qualifications, equipment, etc. 

II. The Sick-Room : its selection, preparation, and management. 

TIL The Patient : duties of the nurse in medical, surgical, obstetric, and gyne- 
cologic cases. 

IV. Nursing in Accidents and Emergencies. 

V. Nursing in Special Medical Cases. 

VI. Nursing of the New-born and Sick Children. 

VII. Physiology and Descriptive Anatomy, 

The Appendix contains much information in compact form that will be found 
of great value to the nurse, including Rules for Feeding the Sick; Recipes for 
Invalid Foods and Beverages ; Tables of Weights and Measures ; Table for 
Computing the Date of Labor; List of Abbreviations : Dose-List; and a full 
and complete Glossary of Medical Terms and Nursing Treatment. 

"This is a well-written, eminently practical volume, which covers the entire range of 
private nursing as distinguished from hospital nursing, and instructs the nurse how best to 
meet the various emergencies which may arise and how to prepare everything ordinarily 
needed in the illness of her patient." — American Journal of Obstetrics and Diseases of 
Women and Children, Aug., i8g6. 

A TEXT-BOOK OF BACTERIOLOGY, including the Etiology and 
Prevention of Infective Diseases and an account of Yeasts and Moulds, 
Hsematozoa, and Psorosperms. By Edgar M. Crookshank, M. B., Pro- 
fessor of Comparative Pathology and Bacteriology, King's College, London. 
A handsome octavo volume of 700 pages, with 273 engravings in the text, 
ana 22 original and colored plates. Price, $6.50 net. 

This book, though nominally a Fourth Edition of Professor Crookshank's 
"Manual of Bacteriology," is practically a new work, the old one having 
been reconstructed, greatly enlarged, revised throughout, and largely rewritten, 
forming a text-book for the Bacteriological Laboratory, for Medical Ofhcers of 
Health, and for Veterinary InsDectot-s. 



28 W. B. SAUNDERS 1 



MEDICAL DIAGNOSIS. By Dr. Oswald Vierordt, Professor of 

Medicine at the University of Heidelberg. Translated, with additions, 
from the Fifth Enlarged German Edition, with the author's permission, by 
Francis H. Stuart, A. M., M. D. In one handsome royal-octavo volume 
of 600 pages. 194 fine wood-cuts in the text, many of them in colors. 
Prices: Cloth, $4.00 net; Sheep or Half-Morocco, $5.00 net. 

FOURTH AMERICAN EDITION, FROM THE FIFTH REVISED AND 
ENLARGED GERMAN EDITION. 

In this work, as in no other hitherto published, are given full and accurate 
explanations of the phenomena observed at the bedside. It is distinctly a clin- 
ical work by a master teacher, characterized by thoroughness, fulness, and accu- 
racy. It is a mine of information upon the points that are so often passed over 
without explanation. Especial attention has been given to the germ-theory as a 
factor in the origin of disease. 

The present edition of this highly successful work has been translated from 
the fifth German edition. Many alterations have been made throughout the 
book, but especially in the sections on Gastric Digestion and the Nervous System. 

It will be found that all the qualities which served to make the earlier editions 
so acceptable have been developed with the evolution of the work to its present 
form. 

THE PICTORIAL ATLAS OF SKIN DISEASES AND SYPHI- 
LITIC AFFECTIONS. (American Edition.) Translation from 
the French. Edited by J. J. Pringle, M. B., F. R. C. P., Assistant Phy- 
sician to, and Physician to the department for Diseases of the Skin at, the 
Middlesex Hospital, London. Photo-lithochromes from the famous models 
of dermatological and syphilitic cases in the Museum of the Saint-Louis 
Hospital, Paris, with explanatory wood-cuts and letter-press. In 12 Parts, 
at $3.00 per Part. 

" Of all the atlases of skin diseases which have been published in recent years, the present 
one promises to be of greatest interest and value, especially from the standpoint of the 
general practitioner." — American Medico-Surgical Bulletin, Feb. 22, 1896. 

"The introduction of explanatory wood-cuts in the text is a novel and most important 
feature which greatly furthers the easier understanding of the excellent plates, than which 
nothing, we venture to say, has been seen better in point of correctness, beauty, and general 
merit." — New York Medical Journal , Feb. 15, 1896. 

" An interesting feature of the Atlas is the descriptive text, which is written for each picture 
by the physician who treated the case or at whose instigation the models have been made. 
We predict for this truly beautiful work a large circulation in all parts of the medical world 
where the names St. Louis and Baretta have preceded it." — Medical Record, N. Y., Feb. I, 
1896. 

A TEXT-BOOK OF MECHANO-THERAPY (MASSAGE AND 
MEDICAL GYMNASTICS). By Axel V. Grafstrom, B. Sc, 
M. D., late Lieutenant in the Royal Swedish Army; late House Physi- 
cian, City Hospital, Blackwell's Island, New York. i2mo, 139 pages, 
illustrated. Cloth, $1.00 net. 



CATALOGUE OF MEDICAL WORKS. 2g 

DISEASES OF THE EYE. A Hand-Book of Ophthalmic Prac- 
tice. By G. E. DE Schweinitz, M. D., Professor of Ophthalmology in 
the Jefferson Medical College, Philadelphia, etc. A handsome royal- 
octavo volume of 696 pages, with 255 fine illustrations, many of which are 
original, and 2 chromo-lithographic plates. Prices : Cloth, $4.00 net ; 
Sheep or Half-Morocco, $5.00 net. 

THIRD EDITION, THOROUGHLY REVISED. 

In the third edition of this text-book, destined, it is hoped, to meet the favor- 
able reception which has been accorded to its predecessors, the work has been 
•revised thoroughly, and much new matter has been introduced. Particular 
attention has been given to the important relations which micro-organisms bear 
to many ocular diseases. A number of special paragraphs on new subjects have 
been introduced, and certain articles, including a portion of the chapter on 
Operations, have been largely rewritten, or at least materially changed. A 
number of new illustrations have been added. The Appendix contains a full 
description of the method of determining the corneal astigmatism with the 
ophthalmometer of Javal and Schiotz, and the rotation of the eyes with the 
tropometer of Stevens. 

"A work that will meet the requirements not only of the specialist, but of the general 
practitioner in a rare degree. I am satisfied that unusual success awaits it." 

William Pepper, M. D. 
Provost and Professor of Theory and Practice of Medicine and Clinical Medicine 
in the University of Pennsylvania. 

"A clearly written, comprehensive manual. . . . One which we can commend to students 
as a reliable text-book, written with an evident knowledge of the wants of those entering upon 
the study of this special branch of medical science." — British Medical Journal. 

" It is hardly too much to say that for the student and practitioner beginning the study of 
Ophthalmology, it is the best single volume at present published." — Medical News. 

"It is a very useful, satisfactory, and safe guide for the student and the practitioner, and 
one of the best works of this scope in the English language." — Annals of Ophthalmology. 

DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant 
Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, London ; 
and Arthur E. Giles, M. D., B. Sc, Lond., F. R.C. S., Edin., Assistant 
Surgeon to Chelsea Hospital, London. 436 pages, handsomely illustrated. 
Cloth, $2.50 net. 

The authors have placed in the hands of the physician and student a concise 
yet comprehensive guide to the study of gynecology in its most modern develop- 
ment. It has been their aim to relate facts and describe methods belonging to 
the science and art of gynecology in a way that will prove useful to students for 
examination purposes, and which will also enable the general physician to prac- 
tice this important department of surgery with advantage to his patients and with 
satisfaction to himself. 

" The book is very well prepared, and is certain to be well received by the medical public." 
— British Medical Journal. 

" The text has been carefully prepared. Nothing essential has been omitted, and its 
teachings are those recommended by the leading authorities of the day." — Journal of the 
American Medical Association. 



30 m £. SAUNDEA- 



TEXT-BOOK UPON THE PATHOGENIC BACTERIA, Spe- 

cially written for Students of Medicine. By Joseph McFarland, 
M. D., Professor of Pathology and Bacteriology in the Medico-Chirurgical 
College of Philadelphia, etc. 497 pages, finely illustrated. Price, Cloth, 
$2.50 net, 

SECOND EDITION, REVISED AND GREATLY ENLARGED, 
The work is intended to be a text-book for the medical student and for the 
practitioner who has had no recent laboratory training in this department of medi- 
cal science. The instructions given as to needed apparatus, cultures, stainings, 
microscopic examinations, etc. are ample for the student's needs, and will afford 
to the physician much information that will interest and profit him relative to a 
subject which modern science shows to go far in explaining the etiology of many 
diseased conditions. 

In this second edition the work has been brought up to date in all depart- 
ments of the subject, and numerous additions have been made to the technique 
in the endeavor to make the book fulfil the double purpose of a systematic work 
upon bacteria and a laboratory guide. 

" It is excellently adapted for the medicai students and practitioners for whom it is avowedly 
written. . . . The descriptions given are accurate and readable, and the book should prove 
useful to those for whom it is written. — London Lancet, Aug. 29, 1896. 

" The author has succeded admirably in presenting the essential details of bacteriological 
technics, together with a judiciously chosen summary of our present knowledge of pathogenic 
bacteria. . . . The work, we think, should have a wide circulation among English-speaking 
students of medicine." — N. Y. Medical Journal, April 4, 1896. 

" The book will be found of considerable use by medical men who have not had a special 
bacteriological training, and who desire to understand this important branch of medicai 
science." — Edinburgh Medical Journal, July, 1896. 

LABORATORY GUIDE FOR THE BACTERIOLOGIST. By 

Langdon Frothingham, M. D. V., Assistant in Bacteriology and Veteri- 
nary Science, Sheffield Scientific School. Yale University. Illustrated. 
Price, Clotn. 75 cents. 

The technical methods involved in bacteria-culture, methods of staining, ana 
microscopical study are fully described and arranged as simply and concisely as 
possible. The book is especially intended for use in laboratory work 

" It is a convenient and useful little work, and will more than repay the outlay necessary 
for its purchase in the saving of time which would otherwise be consumed in looking up the 
various points of technique so ciearlv and concisely laid down in its pages." — American Mea.- 
Surg. Bulletin, 

FEEDING IN EARLY INFANCY. By Arthur V. Meigs. M. D. 
Bound in limp cloth, flush edges. Price, 25 cents net. 

Synopsis : Analyses of Milk — Importance of the Subject of Feeding in Early 
Infancy — Proportion of Casein and Sugar in Human Milk — Time to Begin Arti- 
ficial Feeding of Infants — Amount of Food to be Administered at Each Feed- 
ing — Intervals between Feedings — Increase in Amount of Food at Different 
Periods of Infant Development — Unsuitableness of Condensed Milk as a Sub- 
stitute for Mother's Milk — Objections to Sterilization or "Pasteurization" ot 
Milk — Advances made in the Method of Artificial Feeding of Infants, 



CATALOGUE OF MEDICAL WORKS. 3 1 

MATERIA MEDICA FOR NURSES. By Emily A. M. Stoney, 

Graduate of the Training-school for Nurses, Lawrence, Mass. ; late 
Superintendent of the Training-school for Nurses, Carney Hospital, South 
Boston, Mass. Handsome octavo, 300 pages. Cloth, $1.50 net. 

The present book differs from other similar works in several features, all of 
which are introduced to render it more practical and generally useful. The 
general plan of contents follows the lines laid down in training-schools for 
nurses, but the book contains much useful matter not usually included in works 
of this character, such as Poison-emergencies, Ready Dose-list, Weights and 
Measures, etc., as well as a Glossary, defining all the terms in Materia Medica, 
and describing all the latest drugs and remedies, which have been generally 
neglected by other books of the kind. 

ESSENTIALS OF ANATOMY AND MANUAL OF PRACTI- 
CAL DISSECTION, containing " Hints on Dissection." By Charles 
B. Nancrede, M. D., Professor of Surgery and Clinical Surgery in the 
University of Michigan, Ann Arbor; Corresponding Member of the Royal 
Academy of Medicine, Rome, Italy ; late Surgeon Jefferson Medical Col- 
lege, etc. Fourth and revised edition. Post 8vo, over 500 pages, with 
handsome full-page lithographic plates in colors, and over 200 illustrations. 
Price : Extra Cloth or Oilcloth for the dissection-room, $2.00 net. 

Neither pains nor expense has been spared to make this work the most ex- 
haustive yet concise Student's Manual of Anatomy and Dissection ever pub- 
lished, either in America or in Europe. 

The colored plates are designed to aid the student in dissecting the muscles, 
arteries, veins, and nerves. The wood-cuts have all been specially drawn anc( 
engraved, and an Appendix added containing 60 illustrations representing the 
structure of the entire human skeleton, the whole being based on the eleventh 
edition of Gray's Anatomy* 

A MANUAL OF PRACTICE OF MEDICINE. By A. A. Stevens, 
A. M., M. D., Instructor in Physical Diagnosis in the University of Penn- 
sylvania, and Professor of Pathology in the Woman's Medical College of 
Pennsylvania. Specially intended for students preparing for graduation 
and hospital examinations. Post 8vo, 519 pages. Numerous illustrations 
and selected formulae. Price, bound in flexible leather, $2.00 net. 

FIFTH EDITION, REVISED AND ENLARGED. 

Contributions to the science of medicine have poured in so rapidly during the 
last quarter of a century that it is well-nigh impossible for the student, with the 
limited time at his disposal, to master elaborate treatises or to cull from them 
that knowledge which is absolutely essential. From an extended experience in 
teaching, the author has been enabled, by classification, to group allied symp- 
toms, and by the judicious elimination of theories and redundant explanations 
to bring within a comparatively small compass a complete outline of the prac- 
tice of medicine. 



32 W. B. SAUNDERS 9 



MANUAL OF MATERIA MEDICA AND THERAPEUTICS. 

By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the 
University of Pennsylvania, and Professor of Pathology in the Woman's 
Medical College of Pennsylvania. 445 pages. Price, bound in flexible 
leather, $2.25. 

SECOND EDITION, REVISED. 

This wholly new volume, which is based on the last edition of the Pharma- 
copoeia, comprehends the following sections : Physiological Action of Drugs ; 
Drugs; Remedial Measures other than Drugs; Applied Therapeutics; Incom- 
patibility in Prescriptions; Table of Doses; Index of Drugs; and Index of 
Diseases; the treatment being elucidated by more than two hundred formulae. 

" The author is to be congratulated upon having presented the medical student with as 
accurate a manual of therapeutics as it is possible to prepare." — Therapeutic Gazette. 

" Far superior to most of its class ; in fact, it is very good. Moreover, the book is reliable 
and accurate. " — New York Medical Journal. 

" The author has faithfully presented modern therapeutics in a comprehensive work, . . . 
and it will be found a reliable guide."— University Medical Magazine. 

NOTES ON THE NEWER REMEDIES: their Therapeutic Ap- 
plications and Modes of Administration. By David Cerna, M. D., 
Ph. D., Demonstrator of and Lecturer on Experimental Therapeutics in 
the University of Pennsylvania. Post-octavo, 253 pages. Price, #1.25. 

SECOND EDITION, RE-WRITTEN AND GREATLY ENLARGED. 

The work takes up in alphabetical order all the newer remedies, giving their 
physical properties, solubility, therapeutic applications, administration, and 
chemical formula. 

It thus forms a very valuable addition to the various works on therapeutics 
now in existence. 

Chemists are so multiplying compounds, that., if each compound is to be thor- 
oughly studied, investigations must be carried far enough to determine the prac- 
tical importance of the new agents. 

" Especially valuable because of its completeness, its accuracy, its systematic consider- 
ation of the properties and therapy of many remedies of which doctors generally know but 
little, expressed in a brief yet terse manner." — Chicago Clinical Review. 



TEMPERATURE CHART. Prepared by D. T. Laine, M. D. Size 
8x 13)4 inches. Price, per pad of 25 charts, 50 cents. 

A conveniently arranged chart for recording Temperature, with columns for 
daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On they 
back of each chart is given in full the method of Brand in the treatment of 
Typhoid Fever. 



CATALOGUE OF MEDICAL WORKS. 33 



A TEXT-BOOK OF HISTOLOGY, DESCRIPTIVE AND PRAC- 
TICAL. For the Use of Students. By Arthur Clarkson, M. B., 
C. M., Edin., formerly Demonstrator of Physiology in the Owen's College, 
Manchester; late Demonstrator of Physiology in the Yorkshire College, 
Leeds. Large 8vo, 554 pages, with 22 engravings in the text, and 174 
beautifully colored original illustrations. Price, strongly bound in Cloth, 
$4.00 net. 

The purpose of the writer in this work has been to furnish the student of His- 
tology, in one volume, with both the descriptive and the practical part of the 
science. The first two chapters are devoted to the consideration of the general 
methods of Histology ; subsequently, in each chapter, the structure of the tissue 
or organ is first systematically described, the student is then taken tutorially over 
the specimens illustrating it, and, finally, an appendix affords a short note of the 
methods of preparation. 

" The work must be considered a valuable addition to the list of available text-books, and 
is to be highly recommended." — New York Medical Journal. 

" One of the best works for students we have ever noticed. We predict that the book will 
attain a well-deserved popularity among our students." — Chicago Medical Recorder. 

THE PATHOLOGY AND TREATMENT OF SEXUAL IM- 
POTENCE. By Victor G. Vecki, M. D. From the second Ger- 
man edition, revised and rewritten. Demi-octavo, about 300 pages. 
Cloth, $2.00 net. 

The subject of impotence has but seldom been treated in this country in the 
truly scientific spirit that it deserves, and this volume will come to many as a 
revelation of the possibilities of therapeusis in this important field. Dr. Vecki's 
work has long been favorably known, and the German book has received the 
highest consideration. This edition is more than a mere translation, for, although 
based on the German edition, it has been entirely rewritten by the author in 
English. 

" The work can be recommended as a scholarly treatise on its subject, and it can be read 
with advantage by many practitioners."— Journal of the American Medical -Association. 

THE TREATMENT OF PELVIC INFLAMMATIONS 
THROUGH THE VAGINA. By W. R. Pryor, M. D., Pro- 
fessor of Gynecology in the New York Polyclinic. i2mo, 248 pages, 
handsomely illustrated. Cloth, $2.00 net. 

In this book the author directs the attention of the general practitioner to a 
surgical treatment of the pelvic diseases of women. There exists the utmost 
confusion in the profession regarding the most successful methods of treating 
pelvic inflammations ; and inasmuch as inflammatory lesions constitute the ma- 
jority of all pelvic diseases, the subject is an important one. It has been the 
endeavor of the author to put down every little detail, no matter how insig- 
nificant, which might be of service. 



34 W. B. SAUNDERS' 



DISEASES OF WOMEN. By Henry J. Garrigues, A.M., M. D., 
Professor of Gynecology in the New York School of Clinical Medicine; 
Gynecologist to St. Mark's Hospital and to the German Dispensary, New 
York City. In one handsome octavo volume of 728 pages, illustrated by 
335 engravings and colored plates. Prices: Cloth, $4.00 net; Sheep or 
Half-Morocco, $5.00 net. 

A practical work on gynecology for the use of students and practitioners, 
written in a terse and concise manner. The importance of a thorough know- 
ledge of the anatomy of the female pelvic organs has been fully recognized by 
the author, and considerable space has been devoted to the subject. The chap- 
ters on Operations and on Treatment are thoroughly modern, and are based 
upon the large hospital and private practice of the author. The text is eluci- 
dated by a large number of illustrations and colored plates, many of them being 
original, and forming a complete atlas for studying embryology and the anatomy 
of the female genitalia, besides exemplifying, whenever needed, morbid condi- 
tions, instruments, apparatus, and operations. 

Second Edition, Thoroughly Revised. 

The first edition of this work met with a most appreciative reception by the 
medical press and profession both in this country and abroad, and was adopted 
as a text-book or recommended as a book of reference by nearly one hundred 
colleges in the United States and Canada. The author has availed himself of 
the opportunity afforded by this revision to embody the latest approved advances 
in the treatment employed in this important branch of Medicine. He has also 
more extensively expressed his own opinion on the comparative value of the 
different methods of treatment employed. 

"One of the best text-books for students and practitioners which has been published in 
the English language; it is condensed, clear, and comprehensive. The profound learning 
and great clinical experience of the distinguished author find expression in this book in a 
most attractive and instructive form. Young practitioners, to whom experienced consultants 
may not be available, will find in this book invaluable counsel and help." 

Thad. A. Reamy, M. D., LL.D., 
Professor of Clinical Gynecology, Medical College of Ohio ; Gynecologist to the Good 
Samaritan and Cincinnati Hospitals. 



k SYLLABUS OF GYNECOLOGY, arranged in conformity witn 
"An American Text-Book of Gynecology." By J. W. Long, M. D., 
Professor of Diseases of Women and Children, Medical College of Vir- 
ginia, etc. Price, Cloth (interleaved), $1.00 net. 

Based upon the teaching and methods laid down in the larger work, this will 
not only be useful as a supplementary volume, but to those who do not already 
possess the text-book it will also have an independent value as an aid to the 
practitioner in gynecological work, and to the student as a guide in the lecture- 
room, as the subject is presented in a manner at once systematic, clear, succinct, 
?nd practical. 






CATALOGUE OF MEDIC A L WORKS. 3 5 

THE AMERICAN POCKET MEDICAL DICTIONARY. Edited 
by W. A. Newman Dor land, M. D., Assistant Obstetrician to the Hospital 
of the University of Pennsylvania; Fellow of the American Academy of 
Medicine. Containing the pronunciation and definition of all the principal 
words used in medicine and the kindred sciences, with 64 extensive tables. 
Handsomely bound in flexible leather, limp, with gold edges and patent 
thumb index. Price, $1.00 net ; with thumb index, #1.25 net. 

SECOND EDITION, REVISED. 

This is the ideal pocket lexicon. It is an absolutely new book, and not a re- 
vision of any old work. It is complete, defining all the terms of modern medi- 
cine and forming an unusually complete vocabulary. It gives the pronunciation 
of all the terms. It makes a special feature of the newer words neglected by 
other dictionaries. It contains a wealth of anatomical tables of special value to 
students. It forms a handy volume, indispensable to every medical man. 

SAUNDERS' POCKET MEDICAL FORMULARY. By William 
M. Powell, M. D., Attending Physician to the Mercer House for Invalid 
Women at Atlantic City. Containing 1800 Formulae, selected from several 
hundred of the best-known authorities. Forming a handsome and con- 
venient pocket companion of nearly 300 printed pages, with blank leaves 
for Additions; with an Appendix containing Posological Table, Formulae 
and Doses for Hypodermatic Medication, Poisons and their Antidotes, 
Diameters of the Pemale Pelvis and Foetal Head, Obstetrical Table, Diet 
List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, 
Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables 
of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- 
somely bound in morocco, with side index, wallet, and flap. Price, $1-75 
net. 

FIFTH EDITION, THOROUGHLY REVISED. 

"This little book, that can be conveniently carried in the pocket, contains an immense 
amount of material. It is very useful, and as the name of the author of each prescription is 
given, is unusually reliable." — Neiv York Medical Record. 

A COMPENDIUM OF INSANITY. By John B. Chapin, M.D., LL.D., 

Physician-in-Chief, Pennsylvania Hospital for the Insane; late Physician- 
Superintendent of*the Willard State Hospital, New York ; Honorary Mem- 
ber of the Medico-Psychological Society of Great Britain, of the Society of 
Mental Medicine of Belgium. 121110, 234 pages, illust. Cloth, $1.25 net. 

The author has given, in a condensed and concise form, a compendium of 
Diseases of the Mind, for the convenient use and aid of physicians and students. 
It contains a clear, concise statement of the clinical aspects of the various ab- 
normal mental conditions, with directions as to the most approved methods of 
managing and treating the insane. 

" The practical parts of Dr. Chapin's book are what constitute its distinctive merit. We 
desire especially, however, to call attention to the fact that in the subject of the therapeutics 
of insanity the work is exceedingly valuable. The author has made a distinct addition to the 
literature of his specialty." — Philadelphia Medical Journal. 



36 W, B. SAUNDERS' 



AN OPERATION BLANK, with Lists of Instruments, etc. re- 
quired in Various Operations. Prepared by W. W. Keen, M. D., 
LL.D., Professor of Principles of Surgery in the Jefferson Medical Col- 
lege, Philadelphia. Price per Pad, containing Blanks for fifty operations, 
50 cents net. 

SECOND EDITION, REVISED FORM. 

A convenient blank, suitable for all operations, giving complete instructions 
regarding necessary preparation of patient, etc., with a full list of dressings and 
medicines to be employed. 

On the back of each blank is a list of instruments used — viz. general instru 
ments, etc., required for all operations ; and special instruments for surgery of 
the brain and spine, mouth and throat, abdomen, rectum, male and female 
genito-urinary organs, the bones, etc. 

The whole forming a neat pad, arranged for hanging on the wall of a sur- 
geon's office or in the hospital operating-room. 

M Will serve a useful purpose for the surgeon in reminding him of the details of prepa- 
ration for the patient and the room as well as for the instruments, dressings, and antiseptics 
needed " — New York Medical Record 

" Covers about all that can be needed in any operation." — American Lancet. 

" The plan is a capital one." — Boston Medical and Surgical Journal. 

LABORATORY EXERCISES IN BOTANY. By Edson S. Bastin, 
M. A., Professor of Materia Medica and Botany in the Philadelphia Col- 
lege of Pharmacy. Octavo volume of 536 pages, 87 full-page plates. Price, 
Cloth, $2.50. 

This work is intended for the beginner and the advanced student, and it fully 
covers the structure of flowering plants, roots, ordinary stems, rhizomes, tubers, 
bulbs, leaves, flowers, fruits, and seeds. Particular attention is given to the gross 
and microscopical structure of plants, and to those used in medicine. Illustra- 
tions have freely been used to elucidate the text, and a complete index to facil- 
itate reference has been added. 

" There is no work like it in the pharmaceutical or botanical literature of this country, and 
we predict for it a wide circulation." — American Journal of Pharmacy. 

DIET IN SICKNESS AND IN HEALTH. By Mrs. Ernest Hart, 
formerly Student of the Faculty of Medicine of Paris and of the London 
School of Medicine for Women; with an Introduction by Sir Henry 
Thompson, F. R. C. S., M. D., London. 220 pages ; illustrated. Price, 
Cloth, $1.50. 

Useful to those who have to nurse, feed, and prescribe for the sick. In 
each case the accepted causation of the disease and the reasons for the special 
diet prescribed are briefly described. Medical men will find the dietaries and 
recipes practically useful, and likely to save them trouble in directing the dietetic 
treatment of patients. 



CATALOGUE OF MEDICAL WORKS. 37 

A MANUAL OF PHYSIOLOGY, with Practical Exercises. For 

Students and Practitioners. By G. N. Stewart, M. A., M. D., D. Sc., 

lately Examiner in Physiology, University of Aberdeen, and of the New 

Museums, Cambridge University ; Professor of Physiology in the Western 

Reserve University, Cleveland, Ohio. Handsome octavo volume of 848 

pages, with 300 illustrations in the text, and 5 colored plates. Price, Cloth, 

#3.75 net - 

THIRD EDITION, REVISED. 

** It will make its way by sheer force of merit, and amply deserves to do so. It is one oj 

the very best English text-books on the subject. ' ' — London Lancet. 

** Of the many text-books of physiology published, we do not know of one that so nearly 
comes up to the ideal as does Professor Stewart's volume." — British Medical Journal. 

ESSENTIALS OF PHYSICAL DIAGNOSIS OF THE THORAX. 

By Arthur M. Cor win, A. M., M. D., Demonstrator of Physical Diagno- 
sis in the Rush Medical College, Chicago; Attending Physician to the 
Central Free Dispensary, Department of Rhinology, Laryngology, and 
Diseases of the Chest. 219 pages. Illustrated. Cloth, flexible covers. 
Price, $1.25 net. 

THIRD EDITION, THOROUGHLY REVISED AND ENLARGED. 
SYLLABUS OF OBSTETRICAL LECTURES in the Medical 
Department, University of Pennsylvania. By Richard C. Norris, 
A. M., M. D., Lecturer on Clinical and Operative Obstetrics, University 
of Pennsylvania. Third edition, thoroughly revised and enlarged. Crown 
8vo. Price, Cloth, interleaved for notes, $2.00 net. 

" This work is so far superior to others on the same subject that we take pleasure in call- 
ing attention briefly to its excellent features. It covers the subject thoroughly, and will 
prove invaluable both to the student and the practitioner. The author has introduced a 
number of valuable hints which would only occur to one who was himself an experienced 
teacher of obstetrics. The subject-matter is clear, forcible, and modern. We are especially 
pleased with the portion devoted to the practical duties of the accoucheur, care of the child, 
etc. The paragraphs on antiseptics are admirable; there is no doubtful tone in the direc- 
tions given. No details are regarded as unimportant; no minor matters omitted. We ven- 
ture to say that even the old practitioner will find useful hints in this direction which he can- 
not afford to despise." — New York Medical Record. 

A SYLLABUS OF LECTURES ON THE PRACTICE OF SUR- 
GERY, arranged in conformity with " An American Text-Book 
of Surgery." By N. Senn, M. D., Ph. D., Professor of Surgery in Rusl 
Medical College, Chicago, and in the Chicago Polyclinic. Price, $2.00. 

This work by so eminent an author, himself one of the contributors to 
" An American Text-Book of Surgery," will prove of exceptional value to 
the advanced student who has adopted that work as his text-book. It is not 
only the syllabus of an unrivalled course of surgical practice, but it is also an 
epitome of or supplement to the larger work. 

" The author has evidently spared no pains in making his Syllabus thoroughly comprehen* 
sive, and bar. added new matter and alluded to the most recent authors and operations. Full 
references are also given to all requisite details of surgical anatomy and pathology." — British 
Medical Journal, London. 



3 8 W. B. SAUNDERS' 

THE CARE OF THE BABY. By J. P. Crozer Griffith, M. D., 
Clinical Professor of Diseases of Children, University of Pennsylvania; 
Physician to the Children's Hospital', Philadelphia, etc. 404 pages, with 
67 illustrations in the text, and 5 plates. i2mo. Price, $1.50. 

SECOND EDITION, REVISED. 

A reliable guide not only for mothers, but also for medical students and 
practitioners whose opportunities for observing children have been limited. 

" The whole book is characterized by rare good sense, and is evidently written by a mas. 
ter hand. _ It can be read with benefit not only by mothers, but by medical students and by 
any practitioners who have not had large opportunities for observing children."— A7nerican 
Journal of Obstetrics. 

THE NURSE'S DICTIONARY of Medical Terms and Nursing 

Treatment, containing Definitions of the Principal Medical and Nursing 
Terms, Abbreviations, and Physiological Names, and Descriptions of the 
Instruments, Drugs, Diseases, Accidents, Treatments, Operations, Foods, 
Appliances, etc. encountered in the ward or the sick-room. By Honnor 
Morten, author of " How to Become a Nurse," " Sketches of Hospital 
Life," etc. i6mo, 140 pages. Price, Cloth, $1.00. 

This little volume is intended for use merely as a small reference-book which 
can be consulted at the bedside or in the ward. It gives sufficient explanation 
to the nurse to enable her to comprehend a case until she has leisure to look up 
larger and fuller works on the subject. 

DIET LISTS AND SICK-ROOM DIETARY. By Jerome B. Thomas, 

M. D., Visiting Physicia-n to the Home for Friendless Women and Children 

and to the Newsboys' Home ; Assistant Visiting Physician to the Kings 

- County Hospital; Assistant Bacteriologist, Brooklyn Health Department. 

Price, Cloth, $1.50 (Send for specimen List.) 

One hundred and sixty detachable (perforated) diet lists for Albuminuria, 
Anaemia and Debility, Constipation, Diabetes, Diarrhoea, Dyspepsia, Fevers, 
Gout or Uric- Acid Diathesis, Obesity, and Tuberculosis. Also forty detachable 
sheets of Sick-Room Dietary, containing full instructions for preparation of 
easily-digested foods necessary for invalids. Each list is nu?nbered onfy, the 
disease for which it is to be used in no case being mentioned, an index key 
being reserved for the physician's private use. 

DIETS FOR INFANTS AND CHILDREN IN HEALTH AND 
IN DISEASE. By Louis Starr, M. D., Editor of "An American 
Text-Book of the Diseases of Children." 230 blanks (pocket-book size), 
perforated and neatly bound in flexible morocco. Price, $1.25 net. 

The first series of blanks are prepared for the first seven months of infanl 
life; each blank indicates the ingredients, but not the qziantities, of the food, 
the latter directions being left for the physician. After the seventh month, 
modifications being less necessary, the diet lists are printed in full. Formula 
to: tne preparation of diluents and foods are appended. 



CATALOGUE OF MEDICAL WORKS. 39 

HOW TO EXAMINE FOR LIFE INSURANCE. By Jofn M. 
Keating, M. D., Fellow of the College of Physicians and Surgeons of 
Philadelphia; Vice-President of the American Psediatric Society; Ex- 
President of the Association of Life Insurance Medical Directors. Royal 
8vo, 211 pages, with two large half-tone illustrations, and a plate prepared 
by Dr. McClellan from special dissections ; also, numerous cuts to elucidate 
the text. Third edition. Price, Cloth, $2.00 net. 

" This is by far the most useful book which has yet appeared on insurance examination, a 
subject of growing interest and importance. Not the least valuable portion of the volume is 
Part II., which consists of instructions issued to their examining physicians by twenty-four 
representative companies of this country. As the proofs of these instructions were corrected 
by the directors of the companies, they form the latest instructions obtainable. If for these 
alone, the book should be at the right hand of every physician interested in this special branch 
of medical science." — The Medical News, Philadelphia. 

NURSING: ITS PRINCIPLES AND PRACTICE. By Isabel 
Adams Hampton, Graduate of the New York Training School for 
Nurses attached to Bellevue Hospital; Superintendent of Nurses and 
Principal of the Training School for Nurses, Johns Hopkins Hospital, 
Baltimore, Md. ; late Superintendent of Nurses, Illinois Training School 
for Nurses, Chicago, 111. In one very handsome i2mo volume of 512 
pages, illustrated. Price, Cloth, $2.00 net. 

SECOND EDITION, REVISED AND ENLARGED. 

This original work on the important subject of nursing is at once comprehensive 
and systematic. It is written in a clear, accurate, and readable style, suitable 
alike to the student and the lay reader. Such a work has long been a desidera- 
tum with those entrusted with the management of hospitals and the instruction of 
nurses in training-schools. It is also of especial value to the graduated nurse 
who desires to acquire a practical working knowledge of the care of the sick 
and the hygiene of the sick-room. 

OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERA- 
TIONS. By L. Ch. Boisliniere, M. D., late Emeritus Professor of 
Obstetrics in the St. Louis Medical College. 381 pages, handsomely illus- 
trated. Price, $2.00 net. 

" For the use of the practitioner who, when away from home, has not the 
opportunity of consulting a library or of calling a friend in consultation. He 
then, being thrown upon his own resources, will find this book of benefit in 
guiding and assisting him in emergencies." 

INFANT'S WEIGHT CHART. Designed by J. P. Crozer Grjffzth, 
M. D., Clinical Professor of Diseases of Children in the University of Peni* 
sylvania. 25 charts in each pad. Price per pad, 50 cents net. 

A convenient blank for keeping a record of the child's weight during the first 
two years of life. Printed on each chart is a curve representing the average weight 
of a healthy infant, so that any deviation from the normal can readily be detected. 




saunders' 
New Series 
of Manuals 



for Students 
and 
Practitioners* 



THAT there exists a need for thoroughly reliable hand-books on the leading 
branches of Medicine and Surgery is a fact amply demonstrated by the 
favor with which the SAUNDERS NEW SERIES OF MANUALS have been 
received by medical students and practitioners and by the Medical Press. 
These manuals are not merely condensations from present literature, but 
are ably written by well-known authors and practitioners, most of them being 
teachers in representative American colleges. Each volume is concisely and 
authoritatively written and exhaustive in detail, without being encumbered 
with the introduction of "cases," which so largely expand the ordinary text- 
book. These manuals will therefore form an admirable collection of advanced 
lectures, useful alike to the medical student and the practitioner: to the latter, 
too busy to search through page after page of elaborate treatises for what he 
wants to know, they will prove of inestimable value ; to the former they will 
afford safe guides to the essential points of study. 

The SAUNDERS NEW SERIES OF MANUALS are conceded to be 
superior to any similar books now on the market. No other manuals afford so 
much information in such a concise and available form. A liberal expenditure 
has enabled the publisher to render the mechanical portion of the work worthy 
of the high literary standard attained by these books. 

Any of these Manuals will be mailed on receipt of price (see next page 
for List). 



SAUNDERS' NEW SERIES OF MANUALS. 



VOLUMES PUBLISHED. 



PHYSIOLOGY. By Joseph Howard Raymond, A. M., M. D., Professor 
of Physiology and Hygiene and Lecturer on Gynecology in the Long 
Island College Hospital, etc. Price, J 1. 25 net. 

SURGERY, General and Operative. By John Chalmers DaCosta, 
M. D., Professor of Clinical Surgery, Jefferson Medical College, Philadel- 
phia. Second edition, revised and greatly enlarged. Octavo, 91 1 pages, 
386 illustrations. Cloth, $4.00 net; Half-Morocco, $5.00 net. 

DOSE-BOOK AND MANUAL OF PRESCRIPTION- WRITING. 

By E. Q. Thornton, M. D., Demonstrator of Therapeutics, Jefferson 
Medical College, Philadelphia. Price, $1.25 net. 

MEDICAL JURISPRUDENCE. By Henry C. Chapman, M. D., Pro- 
fessor of Institutes of Medicine and Medical Jurisprudence in the Jeffer- 
son Medical College of Philadelphia, etc. Price, $1.50 net. 

SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's 
Hospital and to the German Poliklinik ; Instructor in Surgery, New York 
Post-Graduate Medical School, etc. Price, J 1.25 net. 

MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct 
Professor of Anatomy and Demonstrator of Anatomy, Medical Department 
of the New York University, etc. Price, $2.50 net. 

SYPHILIS AND THE VENEREAL DISEASES. By James 
Nevins Hyde, M. D., Professor of Skin and Venereal Diseases, and 
Frank H. Montgomery, M. D., Lecturer on Dermatology and Genito- 
urinary Diseases in Rush Medical College, Chicago. Price, $2.50 net. 

PRACTICE OF MEDICINE. By George Roe Lockwood, M. D., 
Professor of Practice in the Woman's Medical College of the New York 
Infirmary, etc. Price, $2.50 net. 

OBSTETRICS. By W. A. Newman Dorland, M. D., Assistant Demon- 
strator of Obstetrics, University of Pennsylvania; Chief of Gynecological 
Dispensary, Pennsylvania Hospital. Price, $2.50 net. 

DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant 
Surgeon to the Middlesex Hospital, and Surgeon to the Chelsea Hospital 
for Women, London ; and Arthur E. Giles, M. D., B. Sc. Lond., F. R. C. S. 
Edin., Assistant Surgeon to the Chelsea Hospital for Women, London. 436 
pages, handsomely illustrated. Price, $2.50 net. 

IN PREPARATION. 

NERVOUS DISEASES. By Charles W. Burr, M. D„ Clinical Profes- 
sor of Nervous Diseases, Medico-Chirurgical College, Philadelphia, etc. 

*** There will be published in the same series, at short intervals, carefully prepared works 
on various subjects, by prominent specialists. 



SAUNDERS' QUESTION COMPENDS. 

Arranged in Question and Answer Form, 

THE LATEST, MOST COMPLETE, and BEST ILLUSTRATED 
SERIES OF COMPENDS EVER ISSUED. 



Now the Standard Authorities in Medical Literature 



Students and Practitioners in every City of the United 
States and Canada. 



THE REASON WHY. 

They are the advance guard of " Student's Helps " — that DO help; they are 
the leaders in their special line, well and atithoritatively written by able men, 
who, as teachers in the large colleges, know exactly what is wanted by a student 
preparing for his examinations. The judgment exercised in the selection of 
authors is fully demonstrated by their professional elevation. Chosen from the 
ranks of Demonstrators, Quiz-masters, and Assistants, most of them have be- 
come Professors and Lecturers in their respective colleges. 

Each book is of convenient size (5x7 inches), containing on an average 250 
pages, profusely illustrated, and elegantly printed in clear, readable type, on 
fine paper. 

The entire series, numbering twenty-four subjects, has been kept thoroughly 
revised and enlarged when necessary, many of them being in their fourth and 
fifth editions. 

TO SUM UP. 

Although there are numerous other Quizzes, Manuals, Aids, etc. in the mar- 
ket, none of them approach the " Blue Series of Question Compends;" and 
the claim is made for the following points of excellence : 

1. Professional distinction and reputation of authors. 

2. Conciseness, clearness, and soundness of treatment. 

3. Size of type and quality of paper and binding. 

* :f: * Any of these Compends will be mailed on receipt of price (see next 
page for List). 



1 



SAUNDERS' QUESTION-COMPEND SERIES. 



Price, Cloth, $L00 per copy, except wfien otherwise noted* 



1. ESSENTIALS OF PHYSIOLOGY. 4th edition. Illustrated. Revised and enlarged. 

By H. A. Hare, M. D. (Price, #1.00 net.) 

2. ESSENTIALS OF SURGERY. 7th edition, with a chapter on Appendicitis. 90 illus- 

trations. By Edward Martin, M. D. (Price, $1.00 net.) 

3. ESSENTIALS OF ANATOMY. 6th edition, thoroughly revised. 151 illustrations. 

By Charles B. Nancrede, M. D. (Price, $1.00 net.) 

4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 

5th edition, revised, with an Appendix. By Lawrence Wolff, M. D. ($1.00 net.) 

5. ESSENTIALS OF OBSTETRICS. 4th edition, revised and enlarged. 75 illustra- 

tions. By W. Easterly Ashton, M. D. 

6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. 7 th thousand. 

46 illustrations. By C. E. Armand Semple, M. D. 

7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- 

SCRIPTION-WRITING. 5th edition. By Henry Morris, M. D. 

8. g. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M.D. 

An Appendix on Urine Examin ation. Illustrated. By Lawrence Wolff, M. D. 
3d edition, enlarged by some 300 Essential Formulae, selected from eminent authori- 
ties, by Wm. M. Powell, M. D. (Double number, price #2.00.) 

10. ESSENTIALS OF GYNECOLOGY. 4th edition, revised. With 62 illustrations. 

By Edwin B. Cragin, M. D. 

11. ESSENTIALS OF DISEASES OF THE SKIN. 4th edition, revised and enlarged. 

71 letter-press cuts and 15 half-tone illustrations. By Henry W. Stelwagon, M.D. 
(Price, $1.00 net.) 

12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL 

DISEASES. 2d edition, revised and enlarged. 78 illustrations. By Edward 
Martin, M. D. 

13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 

130 illustrations. By C. E. Armand Semple, M. D. 

14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 124 

illustrations. 2d edition, revised. By Edward Jackson, M. D., and E. Baldwin 
Gleason, M. D. 

15. ESSENTIALS OF DISEASES OF CHILDREN. 2d edition. By William M. 

Powell, M. D. 

16. ESSENTIALS OF EXAMINATION OF URINE. Colored " Vogel Scale/' 

and numerous illustrations. By Lawrence Wolff, M. D. (Price, 75 cents.) 

17. ESSENTIALS OF DIAGNOSIS. 2d edition, thoroughly revised. 60 illustrations. 

By S. Solis-Cohen, M. D., and A. A. Eshner, M. D. (Price, $1.00 net.) 

18. ESSENTIALS OF PRACTICE OF PHARMACY. 2d edition, revised. By L. 

E. Sayre. 

20. ESSENTIALS OF BACTERIOLOGY. 3d edition. 82 illustrations. By M. V. 

Ball, M. D. 

21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. 48 illustrations. 

3d edition, revised. By John C. Shaw, M. D. 

22. ESSENTIALS OF MEDICAL PHYSICS. 155 illustrations. 2d edition, revised. 

By Fred J. Brockway, M. D. (Price, $1.00 net.) 

23. ESSENTIALS OF MEDICAL ELECTRICITY. 65 illustrations. By David D. 

Stewart, M. D., and Edward S. Lawrance, M. D. 

24. ESSENTIALS OF DISEASES OF THE EAR. 114 illustrations. 2d edition, re- 

vised and enlarged. By E. Baldwin Gleason, M. D. 

43 



Some of the Books in Preparation for 
Publication during 1900- 



AMERICAN Text=Book of Pa= 
thology. 

Edited by Ludvig Hektoen, M.D., Pro- 
fessor of Pathology, Rush Medical College,. 
Chicago; and David Riesman, M.D., De- 
monstrator of Pathological Histology, Uni- 
versity of Pennsylvania. 

AMERICAN Text=Book of Legal 
Medicine and Toxicology. 

Edited by Frederick Peterson, M.D., 
Chief of Clinic, Nervous Department, College 
of Physicians and Surgeons, New York City ; 
and 'Walter S. Haines, M.D., Professor of 
Chemistry, Pharmacy, and Toxicology, Rush 
Medical College, Chicago. 

BECK— Fractures. 

By Carl Beck, M.D., Professor of Surgery 
in the N. Y. School of Clinical Medicine. 

BOHM, DAVIDOFF, and HU= 
BER— A Text=Book of Human 
Histology. 

Including Microscopic Technic. By 
Dr. A. A. Bohm and Dr. M. von Davidoff, 

of the Anatomical Institute of Munich, and 
G. C. Huber,M.D., Junior Professor of Anat- 
. omy and Histology, University of Michigan, 
Ann Arbor. 

EICHHORST— A Text=Book of 
the Practice of Medicine. 

By Dr. Herman Eichhorst, Professor of 
Special Pathology and Therapeutics and Di- 
rector of the Medical Clinic, University of 
Zurich. Translated and edited by Augustus 
A. Eshner, M.D , Professor of Clinical 
Medicine in the Philadelphia Polyclinic. 

FRIEDRICH — Rhinology, La= 
ryngology, and Otology in 
their Relations to General 
Medicine. 

By Dr. E. P. Friedrich, of the Univer- 
sity of Leipsig. 

LEVY AND KLEMPERER — 
The Elements of Clinical Bac= 
teriology. 

By Dr. Ernst Levy, Professor in the 
University of Strassburg, and Dr. Felix 
Klemperer, Privat-Docent in the Univer- | 
sity of Strassburg. Translated and edited : 
by Augustus A. Eshner, M.D., Professor j 
of Clinical Medicine in the Philadelphia Poly- j 
clinic. Just Ready. Cloth, $2 5c net. J 



McFARLAND— X^ext=Book of 
Pathology. 

By Joseph McFarland, M.D., Professoi 
of Pathology and Bacteriology, Medico-Chi- 
rurgical College, Philadelphia. 

OGDEN — Clinical Examinatio 
of the Urine. 

By J. Bergen Ogden, M.D., Assistant ii 
Chemistry, Harvard Medical School. 

PYLE— A Manual of Persona' 
Hygiene. 

Edited by Walter L. Pyle, M.D., Assi 
tant Surgeon to Wills' Eye Hospital, Philad; 

SCUDDER— The Treatment o 
Fractures. 

By Charles L. Scudder, M.D., Assistar 
in Clinical and Operative Surgery, Harvai 
University. 

SENN— Practical Surgery. 

By Nicholas Senn, M.D., Ph.D., LL.D 

Professor of the Practice of Surgery and • 
Clinical Surgery, Rush Medical College, Cr 
cago. Octavo volume of about 800 page 
profusely illustrated. 

The Pathology andTreatmen 
of Tumors. 

By Nicholas Senn, M.D., Ph.D., LL.D.. 

Professor of the Practice of Surgery and of 
Clinical Surgery, Rush Medical College, Chi- 
cago. A New and Thoroughly Revised Edi- 
tion in preparation. 

STENGEL AND WHITE — The 
Blood in its Clinical and Patho 
logical Relations. 

By Alfred Stengel, M.D., Professor 
Clinical Medicine, University of Penns 
vania; and C. Y. White, M.D., Instn 
tor in Clinical Medicine, University of Pei 
sylvania. 

STEVENS— The Physical Dia 
nosis of Diseases of the Che* 

By A. A. Stevens, A.M., M.D., Lecti 
on Terminology, and Instructor in Phys 
Diagnosis, University of Pennsylvania. 

STONEY — Surgical Techniqu 
for Nurses. 

By Emily A. M. Stoney, late Superi 
tendent of the Training Schools for Nur? 
Carney Hospital, South Boston, Mass. 



